What is the recommended treatment for a patient with a persistent cough and sore throat lasting 12 days?

Management of Persistent Cough and Sore Throat at 12 Days

At 12 days duration, this represents a subacute cough (3-8 weeks), most likely post-infectious in origin, and should be treated with inhaled ipratropium bromide as first-line therapy, with reassurance that spontaneous resolution is expected. 1, 2

Initial Clinical Assessment

At 12 days, your patient falls into the subacute cough category (3-8 weeks duration), which most commonly has a post-infectious origin following a viral upper respiratory tract infection 3, 1, 4. The sore throat component suggests the initial infection involved the upper respiratory tract.

Key diagnostic considerations at this timepoint:

• Rule out pertussis if the patient has paroxysmal cough, post-tussive vomiting, or inspiratory whooping sound—these features warrant nasopharyngeal culture and macrolide antibiotics if confirmed 2, 5
• Obtain chest radiograph only if you suspect pneumonia based on vital sign abnormalities (heart rate ≥100 bpm, respiratory rate ≥24 breaths/min, temperature ≥38°C) or focal consolidation findings on exam (rales, egophony, fremitus) 3, 1
• Do not assume bacterial infection based on purulent sputum alone—purulence results from inflammatory cells and occurs with viral infections 3

Treatment Algorithm for Post-Infectious Cough

First-Line Therapy

Prescribe inhaled ipratropium bromide as it has demonstrated efficacy in controlled trials for attenuating post-infectious cough 2. This addresses the bronchial hyperresponsiveness that commonly persists after viral respiratory infections 3.

Provide reassurance that post-infectious cough resolves spontaneously over time, typically within 3-8 weeks total from symptom onset 2, 5.

What NOT to Do

• Do not prescribe antibiotics unless you have confirmed bacterial sinusitis or pertussis—bacterial infection does not play a role in post-infectious cough pathogenesis 2, 5
• Avoid empiric antibiotic therapy as purulent sputum alone does not indicate bacterial infection requiring antibiotics 3

Second-Line Options (If Ipratropium Fails)

If cough persists beyond 2-3 weeks despite ipratropium and adversely affects quality of life:

• Add inhaled corticosteroids (such as fluticasone) to suppress airway inflammation and bronchial hyperresponsiveness 2, 5
• For severe paroxysms, consider short course of oral prednisone 30-40 mg daily, but only after ruling out other common causes (upper airway cough syndrome, asthma, GERD) 2, 5

When to Reassess for Chronic Cough

If cough persists beyond 8 weeks total, reclassify as chronic cough and initiate systematic evaluation 1, 2:

1. First, treat for upper airway cough syndrome (UACS) with first-generation antihistamine-decongestant combination for 1-2 weeks if patient has nasal discharge, throat clearing, postnasal drip sensation, nasal congestion, or rhinorrhea 1

2. Second, evaluate for asthma if UACS treatment fails—suspect when cough worsens at night, with cold air, or exercise; response to bronchodilators occurs within 1 week but complete resolution may take up to 8 weeks 3, 1

3. Third, initiate intensive GERD therapy if both UACS and asthma treatments fail—requires high-dose PPI, dietary modifications, and lifestyle changes; response may take 2 weeks to several months (sometimes 8-12 weeks) 3, 1

Critical Pitfalls to Avoid

• Failing to recognize the 8-week threshold where post-infectious cough becomes chronic cough requiring different evaluation 1, 2
• Inappropriate antibiotic use for non-bacterial post-infectious cough wastes resources and promotes resistance 2, 5
• Missing back-to-back infections in winter months that can prolong coughing periods significantly 5
• Overlooking pertussis in patients with characteristic paroxysmal features—early macrolide treatment (within first 2 weeks) diminishes symptoms and prevents transmission 2, 5