Outpatient Treatment for Cough with Expectoration and Fever
For an adult outpatient presenting with cough, expectoration, and fever, initiate empiric antibiotics according to local guidelines when pneumonia is suspected, but only after clinical assessment confirms features suggestive of pneumonia rather than simple acute bronchitis. 1
Initial Clinical Assessment
The critical first step is distinguishing pneumonia from acute bronchitis, as this determines whether antibiotics are indicated:
Features Suggestive of Pneumonia (Requiring Antibiotics)
- Fever ≥38°C combined with absence of runny nose 1
- Respiratory findings: breathlessness, crackles, diminished breath sounds on auscultation, or tachypnea 1
- Systemic signs: tachycardia, pleural pain, sweating/shivers, aches and pains 1
- New and localizing chest examination signs 1
Features Suggesting Acute Bronchitis (No Antibiotics Needed)
- Normal vital signs and lung examination 1
- Presence of upper respiratory symptoms (runny nose) 1
- No dyspnea or tachypnea 1
Diagnostic Workup
C-Reactive Protein (CRP) Testing
Measure CRP to strengthen diagnostic accuracy when pneumonia is suspected but clinical findings are equivocal: 1
- CRP >30 mg/L with suggestive symptoms/signs strongly increases pneumonia likelihood 1, 2
- CRP <10 mg/L or 10-50 mg/L without dyspnea and daily fever makes pneumonia unlikely 1, 2
- This test is particularly valuable when deciding whether to initiate antibiotics in settings where imaging cannot be obtained 1
Chest Radiography
Order chest X-ray when abnormal vital signs are present (fever, tachypnea, tachycardia) to improve diagnostic accuracy 1
Microbiological Testing
Routine microbiological testing is not recommended unless results would change therapy 1
Procalcitonin measurement is not routinely recommended in the outpatient setting 1
Treatment Algorithm
If Pneumonia is Suspected or Confirmed
Initiate empiric antibiotics per local/national guidelines: 1
- First-line treatment: Amoxicillin 3 g/day for adults without risk factors 3
- Alternative options for patients with risk factors or suspected atypical pathogens: amoxicillin-clavulanate, second or third-generation cephalosporins (NOT first-generation like cephalexin), or respiratory fluoroquinolones 3, 4
- Treatment duration: 7-14 days for adults 3
- Assess therapeutic response within 48-72 hours after initiating treatment 3
If No Clinical or Radiographic Evidence of Pneumonia
Do not prescribe routine antibiotics when vital signs and lung examination are normal 1, 2
Acute bronchitis is typically viral and antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, gastrointestinal symptoms, and Clostridium difficile infection 5
If Influenza is Suspected
Consider antiviral treatment (oseltamivir or zanamivir) within 48 hours of symptom onset, particularly during influenza season 1
- Antiviral treatment may decrease antibiotic usage, hospitalization, and improve outcomes 1, 2
- Most effective when started within 48 hours 1, 2
Common Pitfalls to Avoid
Avoid prescribing antibiotics for simple acute bronchitis even when fever is present, as most cases are viral 3, 5
Do not assume all cephalosporins are equivalent - first-generation agents like cephalexin have inadequate activity against respiratory pathogens and should not be used 4
Do not change antibiotic therapy within the first 72 hours unless the patient's clinical condition worsens 3
Educate patients that cough typically lasts 2-3 weeks even with appropriate treatment, to set realistic expectations 5
Symptomatic Management
While awaiting antibiotic response or for viral bronchitis: