What is the appropriate management for a patient with a 2-week worsening cough?

Management of 2-Week Worsening Cough

At 2 weeks, this cough is still in the acute phase and requires immediate consideration of pertussis (whooping cough) as the primary diagnosis—if clinical suspicion exists based on paroxysmal episodes, start empirical macrolide antibiotic treatment immediately without waiting for laboratory confirmation. 1

Initial Diagnostic Approach

Classify the Cough Duration

• A 2-week cough is acute (not subacute, which begins at 3 weeks, or chronic, which begins at 8 weeks) 2
• This timing is critical because it changes your differential diagnosis and management strategy 2

Immediately Rule Out Pertussis

• Any cough lasting ≥2 weeks with paroxysmal episodes should be considered pertussis until proven otherwise 1
• Look specifically for: paroxysmal coughing fits, post-tussive vomiting, or inspiratory whooping sound (though absence doesn't exclude the diagnosis) 1
• Do not wait for culture results—start treatment immediately if clinical suspicion exists 1

Key Historical Elements to Obtain

• ACE inhibitor use: Stop the medication regardless of temporal relationship; cough typically resolves within days to 2 weeks (median 26 days) 2
• Smoking status: If current smoker, smoking cessation is first-line; most resolve within 4 weeks 2
• Recent respiratory infection: Helps distinguish post-infectious cough (though this typically presents at 3-8 weeks, not 2 weeks) 2

Treatment Algorithm

If Pertussis is Suspected (Paroxysmal Cough Present)

• Start azithromycin immediately (preferred first-line due to better tolerability): 500 mg once daily for 3-5 days in adults 1, 3
• Alternative: Erythromycin 1-2 g/day for 2 weeks or clarithromycin 1
• Isolate patient for 5 days from start of antibiotic treatment to prevent transmission 1
• Obtain nasopharyngeal aspirate or Dacron swab for culture confirmation, but do not delay treatment 1
• Early treatment (within first 2 weeks) decreases paroxysms and prevents transmission; after 2 weeks, benefit is limited but may still be offered 1

Symptomatic Management for Severe Cough

• Ipratropium inhalation is first-line for cough suppression 1
• Dextromethorphan 60 mg (not over-the-counter doses, which are subtherapeutic) when other measures fail 1
• Prednisone 30-40 mg/day for short period for severe paroxysms 2, 1

If Pertussis is NOT Suspected

• Antibiotics have no role in acute viral cough at 2 weeks 2
• Consider symptomatic treatment with ipratropium if cough is bothersome 2
• Watchful waiting is appropriate—reassess if cough persists beyond 3 weeks 2

When to Escalate or Reassess

Red Flags Requiring Immediate Further Investigation

• Hemoptysis (any amount) 4
• Constitutional symptoms (fever, weight loss, night sweats) suggesting tuberculosis or malignancy 4
• Respiratory distress or hypoxemia 4
• Risk factors for malignancy (age >40, smoking history) 4

Timeline for Reassessment

• At 3 weeks: If cough persists, now consider post-infectious cough (subacute category) and trial ipratropium; consider inhaled corticosteroids if quality of life is affected 2
• At 8 weeks: If cough persists, evaluate as chronic cough with full workup for upper airway cough syndrome, asthma, non-asthmatic eosinophilic bronchitis, and gastroesophageal reflux disease 2

Critical Pitfalls to Avoid

• Do not delay pertussis treatment waiting for laboratory confirmation—effectiveness decreases significantly after the first 2 weeks of symptoms 1
• Do not use antibiotics indiscriminately for viral post-infectious cough where they provide no benefit 2
• Do not use subtherapeutic doses of cough suppressants—over-the-counter dextromethorphan is insufficient; 60 mg is needed for optimal effect 1
• Do not misclassify as chronic cough—at 2 weeks, this is still acute phase with different management implications 2
• Do not forget isolation precautions if pertussis is diagnosed—patient remains contagious until 5 days after starting antibiotics 1