Why is the patient still coughing after completing antibiotic treatment for Pneumonia (PNA)?

From the Guidelines

The patient may still be coughing after completing antibiotics for pneumonia because cough can persist for 6-8 weeks after pneumonia resolves, even with appropriate treatment. This lingering cough occurs because inflammation in the airways takes time to heal completely, even after the infection has been cleared 1. Other possible explanations include an incomplete treatment of the original infection, development of a different respiratory condition like post-infectious bronchitis, underlying asthma exacerbated by the pneumonia, or gastroesophageal reflux disease causing persistent cough.

Some key points to consider in the management of postinfectious cough include:

• The optimal treatment is not known, but therapy with antibiotics has no role, as the cause is not bacterial infection 1
• Consider a trial of inhaled ipratropium as it may attenuate the cough 1
• In patients with postinfectious cough, when the cough adversely affects the patient’s quality of life and when cough persists despite use of inhaled ipratropium, consider the use of inhaled corticosteroids 1
• For severe paroxysms of postinfectious cough, consider prescribing 30 to 40 mg of prednisone per day for a short, finite period of time when other common causes of cough have been ruled out 1

If the cough is improving gradually without other concerning symptoms like fever or worsening shortness of breath, it's likely part of the normal recovery process. However, if the cough is worsening, accompanied by fever, chest pain, or increased sputum production, the patient should be reevaluated as they may need additional treatment or investigation for complications or alternative diagnoses 1. Supportive measures like staying hydrated, using honey for soothing (if over 1 year old), and avoiding irritants like smoke can help manage the lingering cough while recovery continues.

From the FDA Drug Label

Treatment of pneumonia In the treatment of pneumonia, azithromycin has only been shown to be safe and effective in the treatment of community-acquired pneumonia due to Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy The patient may still be coughing after finishing antibiotic treatment for PNA because azithromycin only treats specific types of community-acquired pneumonia, and the patient's symptoms may persist if the underlying cause is not fully addressed or if the patient has developed a secondary condition such as Clostridium Difficile-associated diarrhea 2.

• Possible reasons for persistent cough include:
  • Incomplete treatment of the underlying infection
  • Development of a secondary infection or condition
  • Other underlying health issues that may compromise the patient's ability to respond to treatment It is essential to re-evaluate the patient's condition and consider further testing or alternative treatments to determine the cause of the persistent cough.

From the Research

Possible Causes of Persistent Cough

• The patient may still be coughing after finishing antibiotic treatment for PNA due to various reasons, including:
  • Upper airway cough syndrome
  • Gastroesophageal reflux disease/laryngopharyngeal reflux disease
  • Asthma
  • Nonasthmatic eosinophilic bronchitis 3
• Other potential causes of chronic cough include:
  • Angiotensin-converting enzyme inhibitor use
  • Environmental triggers
  • Tobacco use
  • Chronic obstructive pulmonary disease
  • Obstructive sleep apnea 3

Evaluation and Management

• Patients with persistent cough should be evaluated clinically, including spirometry if indicated, and empiric treatment should be initiated 3
• Chest radiography can rule out concerning infectious, inflammatory, and malignant thoracic conditions 3
• Patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist, and may benefit from a trial of gabapentin, pregabalin, and/or speech therapy 3

Antibiotic Treatment

• The optimal duration of antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is unknown, but studies suggest that 3-day treatment with amoxycillin-clavulanic acid can be a safe and effective alternative to the standard 10-day treatment for hospitalised patients with AECOPD who have improved after initial therapy for 3 days 4
• Azithromycin and amoxicillin have similar efficacy and tolerability in the treatment of acute exacerbation of chronic obstructive pulmonary disease 5
• Oral amoxicillin-clavulanate and azithromycin are effective in achieving symptom resolution of non-severe exacerbations in children with bronchiectasis 6