What is the recommended treatment for a patient with a cough and upper respiratory infection?

Treatment of Cough and Upper Respiratory Infection

For patients with cough and upper respiratory infection, symptomatic treatment is recommended as most cases are self-limiting, with antibiotics generally not indicated unless specific risk factors are present. 1

Initial Assessment and Classification

• Determine if the cough is acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide treatment approach 2
• Rule out pneumonia and other serious conditions requiring specific treatment 1
• Consider underlying causes such as postinfectious inflammation, upper airway cough syndrome, or asthma 2

First-Line Treatment Recommendations

Symptomatic Relief for Uncomplicated URIs

• Dextromethorphan can be prescribed for patients with a dry and bothersome cough, particularly when it disrupts sleep 1
• Codeine may be considered for short-term symptomatic relief in patients with chronic bronchitis but has limited efficacy for URI-related cough 1
• Inhaled ipratropium bromide is the only recommended inhaled anticholinergic agent for cough suppression in URI or bronchitis 1, 2

Medications to Avoid

• Expectorants, mucolytics, and antihistamines should not be prescribed in acute LRTI in primary care as consistent evidence for beneficial effects is lacking 1
• Antibiotics have no role in treating uncomplicated URI or postinfectious cough as most cases are viral in origin 1, 2
• Over-the-counter combination cold medications are not recommended until randomized controlled trials prove they are effective cough suppressants 1, 3

Treatment Algorithm Based on Cough Duration and Type

For Acute Cough (<3 weeks)

• For dry, bothersome cough:

  • Dextromethorphan for symptomatic relief 1
  • Consider ipratropium bromide if cough is particularly troublesome 1, 2

• For productive cough:

  • Avoid cough suppression as cough helps clear mucus 1
  • Guaifenesin may help loosen phlegm, though evidence is limited 4, 5

For Postinfectious Cough (3-8 weeks)

• First-line: Inhaled ipratropium bromide 1, 2
• Second-line: Consider inhaled corticosteroids when cough adversely affects quality of life and persists despite ipratropium 1
• Third-line: For severe paroxysms, consider short-term prednisone (30-40 mg daily) when other causes have been ruled out 1
• Fourth-line: Central acting antitussives (codeine, dextromethorphan) when other measures fail 1

Special Considerations

When to Consider Antibiotics

Antibiotic treatment should be considered only in patients with:

• Suspected or definite pneumonia 1
• Age >75 years with fever 1
• Cardiac failure 1
• Insulin-dependent diabetes mellitus 1
• Serious neurological disorders 1
• Suspected pertussis infection (paroxysmal cough with post-tussive vomiting or inspiratory whooping sound) 1, 2

High-Risk Patients

• Consider that serious chronic diseases (asthma, COPD, cardiac failure, diabetes) may flare up during LRTI 1
• Temporarily adjust dosages of chronic medications as needed 1

Common Pitfalls to Avoid

• Prescribing antibiotics for viral infections, which provides no benefit and contributes to antibiotic resistance 1
• Using cough suppressants when the cough is productive and helping to clear mucus 1
• Overlooking pertussis in patients with prolonged cough (≥2 weeks) accompanied by paroxysms, post-tussive vomiting, or inspiratory whooping sound 1
• Using over-the-counter combination medications without evidence of effectiveness 1, 3, 6
• Failing to recognize when cough persists beyond expected timeframes, which may indicate a more serious condition 1

Most cases of cough due to URI are self-limiting and will resolve within 1-3 weeks without specific treatment 1, 6. Patient education about the natural course of the illness and appropriate symptomatic management is essential to avoid unnecessary medication use.