What is the best course of action for a flu-positive patient with a hoarse voice and sore throat, currently on a Z-pack (azithromycin), after coughing up a swallowed wrapper?

Management of Flu-Positive Patient with Hoarse Voice and Sore Throat on Azithromycin

The Z-pack (azithromycin) is not indicated for uncomplicated influenza with sore throat and should be discontinued unless there are signs of bacterial superinfection or pneumonia. 1

Immediate Assessment Required

Evaluate for complications requiring antibiotic continuation:

• Check for pneumonia: Examine for focal chest signs, dyspnea, or respiratory distress that would indicate influenza-related pneumonia requiring antibiotics 1
• Assess for bacterial superinfection: Look for recrudescent fever (fever returning after initial improvement), worsening dyspnea, or purulent sputum production 1
• Evaluate the wrapper aspiration: Determine if there is evidence of aspiration pneumonitis, foreign body retention, or secondary bacterial infection from the aspiration event 1

Antibiotic Decision Algorithm

If NO pneumonia or bacterial complications present:

Discontinue the azithromycin immediately. Previously well adults with acute bronchitis complicating influenza, in the absence of pneumonia, do not routinely require antibiotics 1

If bacterial superinfection or pneumonia IS present:

Switch from azithromycin to co-amoxiclav 625 mg three times daily orally as the preferred antibiotic choice for influenza-related respiratory complications 1, 2

Rationale for switching: Co-amoxiclav provides superior coverage against the key bacterial pathogens in influenza complications (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae) compared to azithromycin, and addresses beta-lactamase producing organisms 1, 2

Alternative if penicillin allergy: Doxycycline 200 mg loading dose, then 100 mg once daily 1

Antiviral Consideration

Assess eligibility for oseltamivir (Tamiflu):

• Start oseltamivir 75 mg twice daily for 5 days if: The patient has been symptomatic for ≤48 hours AND has fever >38°C 1
• Consider oseltamivir even if >48 hours symptomatic if: The patient is severely ill, immunocompromised, or has high-risk features, though evidence for benefit is limited in this scenario 1

Addressing the Wrapper Aspiration

Ensure complete evaluation of the aspiration event:

• Confirm wrapper was completely expelled: If any doubt exists about retained foreign body, obtain chest X-ray 1
• Monitor for aspiration pneumonitis: Watch for fever, productive cough, or respiratory symptoms developing 24-48 hours post-aspiration 1
• If aspiration pneumonia suspected: This would constitute a clear indication for antibiotics with co-amoxiclav 625 mg three times daily as first-line therapy 1

Symptom Management for Hoarseness and Sore Throat

Supportive care is the mainstay for viral pharyngitis:

• Hoarseness with influenza is typically viral laryngitis and does not require antibiotics 3, 4
• Sore throat from influenza resolves in 82% of patients within one week without antibiotics 3
• Antibiotics reduce sore throat symptoms modestly (NNTB = 6 at day 3), but this benefit must be weighed against antimicrobial resistance concerns 3

Critical Pitfalls to Avoid

Do not continue azithromycin "just to finish the course" if there is no bacterial indication—this contributes to antimicrobial resistance without clinical benefit 1, 3

Do not assume the wrapper aspiration automatically requires antibiotics unless there is evidence of pneumonitis or retained foreign body 1

Do not miss the narrow window for antiviral therapy—oseltamivir is most effective when started within 48 hours of symptom onset 1

Follow-Up Parameters

Reassess in 48-72 hours if antibiotics are started to confirm clinical improvement 2

Return immediately if: Worsening dyspnea, high fever, chest pain, or inability to maintain hydration develops 1