What is the approach to a patient presenting with cough and fever?

Approach to Patient with Cough and Fever

The initial approach to a patient with cough and fever should first determine whether the condition represents a serious illness such as pneumonia or pulmonary embolism, or a non-life-threatening disease such as a respiratory tract infection. 1

Initial Assessment

• Perform a focused medical history to determine if the patient is taking an ACE inhibitor, is a smoker, or has evidence of serious life-threatening systemic disease. 1
• Assess for signs of respiratory distress including markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs, cyanosis, severe dehydration, altered conscious level, or complicated seizures. 1
• Evaluate for risk factors for complications including comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions. 1

Diagnostic Approach

• Obtain a chest radiograph if pneumonia is suspected based on clinical findings such as tachypnea, tachycardia, dyspnea, or abnormal lung findings. 1, 2
• Consider C-reactive protein measurement - pneumonia can be ruled out in patients with C-reactive protein values below 10 μg/ml or in patients with C-reactive protein between 11 and 50 μg/ml without dyspnea and daily fever. 3
• For patients with chronic cough (>8 weeks), consider chest radiography to rule out serious underlying conditions. 4

Management Based on Duration and Severity

Acute Cough (<3 weeks)

• For mild symptoms (cough and low-grade fever):

  • Recommend adequate fluid intake to avoid dehydration (no more than 2 liters per day). 1
  • Consider honey for cough suppression in patients over 1 year of age. 1
  • Advise patients to take paracetamol for fever and associated symptoms. 1

• For moderate symptoms with high fever (>38.5°C):

  • Consider empiric antibiotic therapy if bacterial infection is suspected. 1
  • Avoid empiric antibiotics for uncomplicated acute bronchitis as it typically provides minimal benefit (reducing illness by only about half a day) and has potential adverse effects. 2

• For severe symptoms or signs of pneumonia:

  • Initiate appropriate antibiotic therapy based on likely pathogens. 1, 5
  • Consider hospital admission for patients with severe respiratory distress, hypoxemia, or significant comorbidities. 1

Subacute Cough (3-8 weeks)

• Determine if it is a postinfectious cough or not. 1
• If postinfectious, evaluate for upper airway cough syndrome (UACS), transient bronchial hyperresponsiveness, asthma, pertussis, or acute exacerbation of chronic bronchitis. 1
• If non-infectious, manage as chronic cough. 1

Chronic Cough (>8 weeks)

• Systematically direct empiric treatment at the most common causes: upper airway cough syndrome (UACS), asthma, non-asthmatic eosinophilic bronchitis (NAEB), and gastroesophageal reflux disease (GERD). 1
• Apply therapy in sequential and additive steps as more than one cause of cough may be present. 1
• For patients taking ACE inhibitors, discontinue the medication and replace with an alternative. 1
• Consider initial empiric treatment with a first-generation antihistamine/decongestant for UACS. 1

Special Considerations

• In immunocompromised patients, follow the same initial diagnostic algorithm but consider an expanded list of differential diagnoses based on the type and severity of immune defect. 1
• For HIV-infected patients, use CD4+ lymphocyte counts to guide differential diagnosis. 1
• If cough persists despite appropriate evaluation and treatment, consider high-resolution CT scan and bronchoscopic evaluation for uncommon causes. 1
• Avoid dextromethorphan in patients taking MAOIs and use with caution in patients with chronic productive cough or asthma. 6

Common Pitfalls to Avoid

• Don't prescribe antibiotics for viral respiratory infections, as this contributes to antibiotic resistance without providing significant benefit. 2, 3
• Don't rely solely on cough characteristics for diagnosis, as they have limited diagnostic value. 1
• Don't forget to consider uncommon causes when cough persists despite appropriate evaluation and treatment for common causes. 1
• Don't use antipyretics with the sole aim of reducing body temperature without addressing other symptoms. 1