Management of Respiratory Infection with Fever, Productive Cough, and Wheezing
This patient requires immediate evaluation for pneumonia with chest radiography, as the presence of fever, productive cough, and focal findings (crackles in the left lower lobe) strongly suggests pneumonia rather than simple bronchitis, and pneumonia requires antibiotic therapy while bronchitis typically does not. 1
Diagnostic Approach
Suspect Pneumonia When Present:
- New focal chest signs (crackles/rales in left lower lobe) 2, 1
- Fever >4 days duration 2
- Tachypnea (respiratory rate >24 breaths/min) 2
- Tachycardia (pulse >100 beats/min) 2
This patient has focal findings on examination, which increases pneumonia probability from 5-10% to 39% 2. The combination of fever, productive cough, and focal crackles makes pneumonia highly likely 1.
Obtain Chest Radiograph
- Chest X-ray is mandatory to confirm pneumonia diagnosis when clinical suspicion exists based on the above criteria 2
- The gold standard for pneumonia diagnosis remains chest radiography 2
Consider C-Reactive Protein Testing
- CRP >100 mg/L makes pneumonia likely 2, 1
- CRP <20 mg/L with symptoms >24 hours makes pneumonia highly unlikely 2, 1
- CRP can help guide decision-making when clinical picture is uncertain 2
Differentiate from Chronic Airway Disease
The presence of expiratory wheezing raises concern for underlying chronic airway disease (asthma/COPD) rather than simple infection 2.
Evaluate for COPD/Asthma if Patient Has ≥2 of:
- Wheezing (present in this patient) 2
- Prolonged expiration 2
- Smoking history 2
- Symptoms of allergy 2
- Previous consultations for wheezing or cough 2
Lung function testing should be considered in patients meeting these criteria to assess for chronic airway disease 2. Up to 45% of patients with acute cough >2 weeks actually have asthma or COPD 2.
Treatment Algorithm
If Pneumonia is Confirmed:
Initiate antibiotic therapy immediately - pneumonia is a more serious infection than acute bronchitis with higher risk for complications 2, 1.
For Community-Acquired Pneumonia:
- Amoxicillin-clavulanate 875mg/125mg every 12 hours for respiratory tract infections 3
- Alternative: Azithromycin 500mg day 1, then 250mg daily for 4 days for atypical coverage 4, 5
- Amoxicillin-clavulanate should be taken at the start of meals to minimize gastrointestinal intolerance and enhance clavulanate absorption 3
If Acute Bronchitis Without Pneumonia:
Antibiotics are NOT indicated - acute bronchitis is viral and antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects 2, 6. However, the presence of focal findings in this patient makes simple bronchitis unlikely 2.
If Chronic Airway Disease Exacerbation:
Bronchodilators and steroids are beneficial for exacerbations of asthma/COPD 2. Consider β-agonists for wheezing if chronic airway disease is confirmed 2.
Critical Pitfalls to Avoid
Do Not Rely on Sputum Purulence
- Purulent sputum does NOT indicate bacterial infection requiring antibiotics 2
- Purulence results from inflammatory cells and can occur with viral infections 2
Do Not Assume Bronchitis Based on Wheezing Alone
- Wheezing can occur with pneumonia, especially in patients with underlying reactive airway disease 2
- Focal findings (crackles in left lower lobe) strongly favor pneumonia over bronchitis 2, 1
Assess Risk Factors for Complications
In patients >65 years or with the following, monitor carefully and consider referral 2:
- COPD, diabetes, or heart failure 2
- Previous hospitalization in past year 2
- Oral glucocorticoid use 2
- Pulse >100 beats/min 2