What is the best course of treatment for a patient with a persistent, non-productive cough for over 10 days, who has a history of smoking, recently quit 10 days ago, and has recurrent symptoms of cough, congestion, and wheezing despite previous treatment with Augmentin (amoxicillin/clavulanate) and a Z-pack (azithromycin)?

Management of Persistent Non-Productive Cough in Recent Smoking Cessation

This patient requires chest radiograph and spirometry immediately, followed by empiric treatment targeting the three most common causes of chronic cough: upper airway cough syndrome (UACS), asthma/bronchial hyperreactivity, and gastroesophageal reflux disease (GERD), as antibiotics have no role in this clinical scenario. 1, 2

Critical First Steps

Stop repeating antibiotics - this patient has already failed two courses (Augmentin and azithromycin) without fever, and antibiotics have no role in postinfectious or chronic cough when bacterial infection is not present 1. The recurrence after initial improvement suggests the underlying cause was never addressed, not that bacterial infection persists 2.

Mandatory Initial Workup

• Obtain chest radiograph to exclude structural abnormalities, masses, interstitial disease, or congestive heart failure 1, 2
• Perform spirometry with bronchodilator response to assess for airflow obstruction and reversibility 1, 2
• Document smoking history (pack-years) and confirm cessation timeline 1

Understanding This Clinical Picture

Post-Smoking Cessation Cough

The timing is highly relevant - smoking cessation typically leads to cough resolution within 4 weeks in most patients, though it may persist longer 1. However, the presence of wheezing is a red flag that points away from simple post-cessation cough and toward bronchial hyperreactivity or asthma 1, 2.

Why Antibiotics Failed

The patient's initial response to antibiotics followed by recurrence is a classic pattern indicating the wrong diagnosis 2. The non-productive nature, absence of fever, and wheezing strongly suggest non-infectious etiologies 1.

Empiric Treatment Algorithm

Since this cough has persisted >10 days with wheezing and congestion, treat sequentially for the three most common causes, which account for approximately 90% of chronic cough cases 2:

1. Upper Airway Cough Syndrome (UACS) - First Line

• Start first-generation antihistamine-decongestant combination (e.g., chlorpheniramine-pseudoephedrine) 2
• The congestion reported by the patient suggests UACS as a contributing factor 2
• Trial duration: 2-3 weeks before assessing response 1

2. Asthma/Bronchial Hyperreactivity - Concurrent Treatment

The wheezing makes this diagnosis highly likely and requires immediate attention 1, 2:

• Initiate inhaled bronchodilator (e.g., albuterol as needed) 2
• Add inhaled corticosteroid (e.g., fluticasone 220 mcg twice daily or equivalent) 2
• If spirometry shows reversible obstruction, this confirms the diagnosis 1
• If spirometry is normal but wheezing persists, consider bronchoprovocation testing 1
• Trial duration: minimum 2 weeks - cough is unlikely due to eosinophilic airway inflammation if no response to corticosteroids after this period 1

3. Gastroesophageal Reflux Disease (GERD) - Add if No Response

• High-dose proton pump inhibitor (e.g., omeprazole 40 mg twice daily or equivalent) 2
• Minimum treatment duration: 3 months - GERD-related cough requires prolonged acid suppression 1
• GERD can occur without heartburn or regurgitation 1, 2

Critical Pitfalls to Avoid

• Do not prescribe more antibiotics - the patient has no fever, and purulent sputum (if it develops) does not automatically indicate bacterial infection requiring antibiotics 2
• Do not stop treatment prematurely - each therapeutic trial requires adequate duration (2 weeks for bronchodilators/ICS, 3 months for PPIs) 1, 2
• Recognize multiple simultaneous causes - approximately 25% of chronic cough patients have more than one contributing factor, explaining why single-agent therapy may fail 2
• Do not assume smoking cessation alone explains persistent symptoms - the wheezing and recurrent nature after antibiotic courses suggest active pathology beyond simple post-cessation irritation 1

When to Escalate

If symptoms persist despite 4-8 weeks of appropriate empiric therapy:

• High-resolution CT chest to evaluate for bronchiectasis, interstitial lung disease, or occult masses 1, 2
• Bronchoscopy if foreign body aspiration suspected or to evaluate for eosinophilic bronchitis 1, 2
• 24-hour esophageal pH monitoring if GERD suspected but PPI trial failed 2

Special Consideration: Pertussis

While less likely given the clinical picture, pertussis can cause persistent cough lasting ≥2 weeks with paroxysms 1. However, the patient's wheezing and response pattern to antibiotics makes this diagnosis less probable. Consider nasopharyngeal swab for Bordetella pertussis only if paroxysmal coughing with post-tussive vomiting develops 1.