What is the complete workup and management for a 50-year-old male with a 2-week history of cough, sputum production, and fever?

Complete Workup and Management for 50-Year-Old Male with 2-Week Cough, Sputum, and Fever

Immediate Assessment and Risk Stratification

Begin by checking vital signs immediately—look for heart rate ≥100 beats/min, respiratory rate ≥24 breaths/min, or temperature ≥38°C to determine pneumonia risk and severity. 1

• Perform focused lung examination listening specifically for asymmetrical lung sounds, focal consolidation, rales, egophony, or fremitus 1
• Assess for respiratory distress including intercostal retractions, grunting, cyanosis, or altered mental status 2
• Obtain focused history including smoking status, comorbidities (diabetes, COPD, heart disease, HIV), recent hospitalizations, ACE inhibitor use, and exposure to confirmed pertussis cases 3, 1

Diagnostic Workup

Immediate Testing Required

Obtain chest radiograph if any vital sign abnormalities are present, asymmetrical lung sounds are detected, or the patient appears ill. 1

• Order chest X-ray to evaluate for pneumonia (consolidation or bronchopneumonia pattern), lung abscess, or pleural effusion 3, 1
• Collect sputum for Gram stain and culture to identify bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 4, 5
• Obtain nasopharyngeal aspirate or Dacron swab for pertussis culture if cough is paroxysmal, post-tussive vomiting is present, or inspiratory whooping sound is heard 1, 2
• Order paired acute and convalescent sera for fourfold increase in IgG or IgA antibodies to pertussis toxin 1

Additional Testing Based on Clinical Presentation

• If TB risk factors present (high prevalence area, systemic symptoms, weight loss), collect sputum smears and cultures for acid-fast bacilli 1
• If lung abscess suspected on imaging (persistent fever despite antibiotics, foul-smelling sputum), CT chest is indicated to characterize the abscess 3
• Blood cultures if patient appears septic or has high fever 5

Management Algorithm

If Pneumonia Confirmed on Chest X-Ray

Initiate broad-spectrum antibiotics immediately targeting common respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis) based on local antibiotic sensitivities. 3, 4

• Azithromycin 500 mg once daily for 3 days is effective with clinical cure rates of 85% for acute bacterial exacerbations 6
• Alternative: Amoxicillin/clavulanate if beta-lactamase producing organisms suspected 6, 4
• Monitor clinical response at 48-72 hours; if worsening despite antibiotics, obtain CT chest to evaluate for complications (abscess, empyema) 3

If Pertussis Suspected (Paroxysmal Cough, Whooping, Post-Tussive Vomiting)

Initiate macrolide antibiotic immediately—early treatment within the first few weeks diminishes coughing paroxysms and prevents transmission. 1, 2

• Azithromycin is the preferred macrolide with excellent efficacy and lower gastrointestinal side effects compared to alternatives 6
• Do not delay treatment waiting for culture results, as isolation of bacteria takes time 1, 2
• Breakthrough infections occur in vaccinated individuals, so do not rule out pertussis based on vaccination history alone 2

If Lung Abscess Identified on Imaging

Continue broad-spectrum antibiotics for at least 4 weeks, as the majority of lung abscesses (>80%) respond to medical management alone. 3

• If abscess persists or worsens after full course of antibiotics, percutaneous catheter drainage (PCD) is usually appropriate with 83% complete resolution rates 3
• PCD with administration of thrombolytic therapy is an equivalent alternative for refractory cases 3
• Surgical resection reserved for prolonged sepsis, hemoptysis, bronchopleural fistula, or abscess persisting >6 weeks despite treatment 3

If No Pneumonia on Chest X-Ray (Postinfectious Cough)

Consider postinfectious cough when cough follows an obvious preceding respiratory infection, lasts 3-8 weeks, and has no vital sign abnormalities or concerning lung findings. 1

• Underlying mechanisms include postviral airway inflammation, upper airway cough syndrome/postnasal drip, cough-variant asthma, and nonasthmatic eosinophilic bronchitis 1
• If ACE inhibitor use identified, stop the medication—median time to cough resolution is 26 days after discontinuation 1
• Symptomatic treatment with dextromethorphan 60 mg (not standard OTC doses of 15-30 mg which are subtherapeutic) provides maximum cough reflex suppression 7
• Simple home remedies like honey and lemon mixtures can be effective for benign viral cough 3, 7

Critical Red Flags Requiring Immediate Investigation

Obtain chest radiography immediately and consider advanced imaging if any of the following are present: 1

• Hemoptysis
• Significant unintentional weight loss
• Voice changes
• Persistent fever beyond 3 weeks despite appropriate antibiotics
• Asymmetrical lung sounds or focal consolidation

Follow-Up and Reassessment

If cough persists beyond 3 weeks despite appropriate treatment, reassessment is mandatory to rule out other causes rather than continuing empiric therapy. 7, 1

• Cough lasting >3 weeks requires evaluation for post-viral cough, pertussis, tuberculosis, or chronic conditions 7, 1
• If wet cough persists after 4 weeks of appropriate antibiotics, further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT should be undertaken 3
• Consider alternative diagnoses including bronchiectasis, aspiration, immunodeficiency, or malignancy if standard treatments fail 3

Common Pitfalls to Avoid

• Do not rely on cough characteristics alone for diagnosis, as they have limited diagnostic value 2
• Do not use standard over-the-counter dextromethorphan doses (15-30 mg) as they are subtherapeutic 7
• Do not prescribe codeine or pholcodine due to adverse side effect profile including drowsiness, nausea, constipation, and physical dependence 7
• Do not assume pertussis is ruled out in vaccinated individuals 2
• Do not continue antitussive therapy beyond 2-3 weeks without reassessing for underlying causes 7, 1