What is the recommended approach for using steroids in post infectious cough treatment?

Steroid Treatment for Post-Infectious Cough

For severe paroxysms of post-infectious cough, oral prednisone (30-40 mg daily) for a short, finite period is recommended when other common causes of cough have been ruled out and when the cough significantly impacts quality of life. 1, 2

Treatment Algorithm for Post-Infectious Cough

First-Line Therapy

• Inhaled ipratropium bromide should be tried first as it has demonstrated efficacy in attenuating post-infectious cough in controlled trials 2
• Antibiotics have no role in treatment as there is no evidence that bacterial infection plays a role in post-infectious cough 1, 2

Second-Line Therapy

• Inhaled corticosteroids should be considered when cough adversely affects quality of life and persists despite use of inhaled ipratropium 1, 2
• The mechanism of inhaled corticosteroids is thought to be suppression of airway inflammation and bronchial hyperresponsiveness 2, 3
• Extra-fine HFA beclomethasone dipropionate has shown efficacy in reducing cough frequency compared to placebo in post-infectious cough 3

For Severe Cases

• Oral prednisone (30-40 mg daily) tapering over 2-3 weeks may be prescribed for severe paroxysms of post-infectious cough 1, 2
• This should only be considered after ruling out other common causes of cough such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease 1, 2
• The rationale for steroid use is based on the inflammatory processes observed in post-infectious cough, similar to those seen in asthma exacerbations 4, 5

When Other Measures Fail

• Central-acting antitussive agents such as codeine and dextromethorphan should be considered when other treatments fail 1, 2
• Alternative treatments like honey plus coffee have shown promise in some studies for persistent post-infectious cough 6

Special Considerations

Pertussis (Whooping Cough)

• Pertussis requires specific diagnosis and treatment approach different from typical post-infectious cough 1, 2
• Macrolide antibiotics are indicated for confirmed pertussis, and patients should be isolated for 5 days from the start of treatment 2

Common Pitfalls and Caveats

• Failing to recognize when post-infectious cough has persisted beyond 8 weeks, which requires reclassification as chronic cough 2
• Inappropriate use of antibiotics for non-bacterial causes of post-infectious cough 1, 2
• Overlooking underlying conditions that may contribute to persistent cough (asthma, upper airway cough syndrome, GERD) 1, 2
• Failure to respond to treatment should alert clinicians to consider other causes of cough 1

Evidence Quality Assessment

• The evidence for oral corticosteroid use in post-infectious cough is of low quality (grade C) but shows intermediate net benefit 1
• The evidence for inhaled corticosteroids is based on expert opinion with intermediate net benefit (grade E/B) 1
• Research on oral corticosteroids for acute respiratory tract infections is ongoing, with results potentially impacting future recommendations 4, 5