What is the recommended treatment for a patient presenting with a cough and low-grade fever?

Management of Cough and Low-Grade Fever

For a patient presenting with cough and low-grade fever, first determine if this represents a serious illness requiring urgent intervention (pneumonia, pulmonary embolism) versus a self-limited viral upper respiratory infection, then treat accordingly with supportive care for viral illness or antibiotics for confirmed pneumonia. 1

Initial Assessment and Risk Stratification

The critical first step is distinguishing between benign viral illness and serious bacterial infection:

Red flags requiring immediate evaluation include: 1

• Hemoptysis (requires urgent bronchoscopy referral) 1
• Abnormal vital signs (tachycardia, fever ≥38°C, tachypnea) 1
• Breathlessness with crackles or diminished breath sounds on auscultation 1
• Dullness to percussion or bronchial breathing 1
• Purulent sputum with malaise 1

If any of these features are present, suspect pneumonia and obtain a chest radiograph. 1 Consider measuring C-reactive protein (CRP), as levels ≥30 mg/L combined with fever and respiratory signs significantly increase pneumonia likelihood. 1 Conversely, CRP <10 mg/L makes pneumonia unlikely in the absence of dyspnea and daily fever. 1

Treatment for Viral Upper Respiratory Infection (Most Common Scenario)

When vital signs are normal and lung examination reveals no focal findings, this represents acute viral cough requiring only supportive care:

Antipyretic therapy: 1, 2

• Paracetamol (acetaminophen) is preferred over NSAIDs for fever management 1
• Use only while fever and associated symptoms persist 1
• Do not use antipyretics solely to reduce body temperature 1
• Advise regular fluid intake (maximum 2 liters daily) 1

Cough suppression: 1, 3

• First-line: First-generation antihistamine/decongestant combinations (e.g., brompheniramine with sustained-release pseudoephedrine) are most effective 1, 3
• Dextromethorphan 60 mg provides maximum cough reflex suppression (higher than typical over-the-counter doses) 1
• Menthol inhalation offers acute but short-lived relief 1
• Sedating antihistamines may help nocturnal cough 1
• Simple home remedies like honey and lemon are reasonable alternatives 1

Avoid: 1

• Codeine or pholcodine (no greater efficacy than dextromethorphan but significantly more adverse effects) 1
• Newer non-sedating antihistamines (ineffective for acute cough) 1

Treatment for Suspected Pneumonia

When pneumonia is suspected based on clinical findings or imaging: 1

• Initiate empiric antibiotics per local guidelines if imaging cannot be obtained 1
• Routine microbiological testing is unnecessary unless results would change therapy 1

If influenza is suspected: 1

• Start antiviral treatment within 48 hours of symptom onset 1
• This reduces antibiotic usage, hospitalization risk, and improves outcomes 1

Critical Pitfalls to Avoid

Do not routinely prescribe antibiotics for acute cough with normal vital signs and lung examination. 1 This represents viral illness in the vast majority of cases, and antibiotics provide no benefit while contributing to resistance. 1

Do not use dextromethorphan in patients with chronic cough associated with smoking, asthma, or emphysema, or when cough produces excessive phlegm. 4 These conditions require different management approaches. 4

Ensure patients understand the self-limited nature of viral illness (typically resolves within 2 days for cough). 1, 5 This manages expectations and prevents unnecessary medication purchases. 5

When to Seek Further Evaluation

Patients should return if: 1, 3

• Cough persists beyond 7 days or recurs with fever, rash, or persistent headache 4
• Breathlessness develops or worsens 3
• Hemoptysis occurs 3
• Symptoms suggest progression to pneumonia 1

For older patients or those with comorbidities, frailty, or impaired immunity, maintain higher suspicion for bacterial pneumonia as they are more likely to develop severe disease and respiratory failure. 1