What are the next steps for a patient with a persistent cough after completing antibiotics for pneumonia?

From the Guidelines

Patients with a persistent cough after completing antibiotics for pneumonia should be considered for a trial of inhaled ipratropium, as it may attenuate the cough, according to the ACCP evidence-based clinical practice guidelines 1. When a patient presents with an ongoing cough post antibiotics for pneumonia, it is essential to rule out other common causes of cough, such as upper airway cough syndrome (UACS) due to rhinosinus diseases, asthma, or gastroesophageal reflux disease.

• The patient's quality of life and the persistence of the cough despite initial treatments should be assessed.
• Inhaled ipratropium may be considered as a treatment option, as it has been shown to have a fair level of evidence and an intermediate net benefit for attenuating the cough 1.
• If the cough persists and adversely affects the patient's quality of life, inhaled corticosteroids may be considered, although the level of evidence is expert opinion and the grade of evidence is E/B 1.
• For severe paroxysms of postinfectious cough, a short course of prednisone (30-40 mg per day) may be prescribed, but only after ruling out other common causes of cough, and the level of evidence is low 1.
• Central acting antitussive agents, such as codeine and dextromethorphan, should be considered when other measures fail, with a level of evidence of expert opinion and a grade of evidence of E/B 1.

From the Research

Next Steps for Persistent Cough

• The patient's symptoms and medical history should be evaluated to determine the cause of the persistent cough after completing antibiotics for pneumonia 2.
• Clinical criteria, such as stability and patient response, can be used to assess the need for further treatment or to discontinue antibiotic treatment 3.
• Possible causes of chronic cough include upper airway cough syndrome, gastroesophageal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis, and should be considered in the evaluation 2.
• Chest radiography can be used to rule out concerning infectious, inflammatory, and malignant thoracic conditions 2, 4.

Treatment Considerations

• The use of long-term or intermittent antibiotic treatment may be considered in certain cases, such as patients with severe or very severe COPD with frequent or severe exacerbations, but the potential risks and benefits must be carefully weighed 5.
• Shortening antibiotic treatment duration may be possible in some cases, and clinical and biological criteria can be used to customize and shorten treatment duration 3.
• Other treatments, such as bronchodilators and anti-inflammatories, may be effective in managing symptoms and preventing exacerbations 5, 6.

Further Evaluation and Referral

• Patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist for further evaluation and treatment 2.
• Additional tests, such as spirometry, may be necessary to evaluate the patient's condition and determine the best course of treatment 2.