What is the treatment for a 14-year-old with a worsening cough and fever over 2 weeks?

Treatment of 14-Year-Old with Worsening Cough and Fever for 2 Weeks

Start a 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis based on local antibiotic sensitivities, as this presentation is consistent with protracted bacterial bronchitis (PBB). 1

Initial Assessment: Determine Cough Characteristics

The presence of fever with worsening cough over 2 weeks requires immediate classification of whether this is a wet/productive cough versus a dry cough, as this fundamentally changes the treatment pathway. 1, 2

• Wet/productive cough (loose, rattling sound or visible sputum production) indicates bacterial infection requiring antibiotics 1
• Dry cough with fever may suggest atypical infection, pertussis, or other etiologies requiring different evaluation 1, 3

Look for Specific Warning Signs ("Red Flags")

Before initiating treatment, rapidly assess for specific cough pointers that indicate serious underlying disease requiring immediate further investigation rather than empirical antibiotics: 1

• Coughing with feeding (aspiration risk) 1
• Digital clubbing (chronic suppurative lung disease, bronchiectasis) 1
• Hemoptysis 1
• Failure to thrive 1
• Focal chest findings on examination 1

If any of these red flags are present, proceed directly to investigations (chest CT, flexible bronchoscopy, aspiration evaluation, immunologic workup) rather than empirical antibiotic treatment. 1

Treatment Algorithm for Wet/Productive Cough Without Red Flags

First-Line Treatment (Weeks 1-2)

Prescribe a 2-week course of antibiotics targeting common respiratory bacteria. 1 Appropriate choices include:

• Amoxicillin-clavulanate (covers S. pneumoniae, H. influenzae, M. catarrhalis including beta-lactamase producers) 4
• Azithromycin (alternative if penicillin allergy; 10 mg/kg/day for 3-5 days or 30 mg/kg single dose) 4

The fever should resolve within 48-72 hours if bacterial infection is the cause. 1

Reassessment at 2 Weeks

• If cough resolves: Diagnose as protracted bacterial bronchitis (PBB) and monitor for recurrence 1
• If wet cough persists: Administer an additional 2-week course of appropriate antibiotics (same or adjusted based on clinical response) 1

Reassessment at 4 Weeks

If wet cough persists after 4 total weeks of antibiotics, proceed to further investigations: 1

• Flexible bronchoscopy with quantitative bacterial cultures (≥10⁴ cfu/mL confirms microbiologically-based PBB) 1
• Chest CT scan to evaluate for bronchiectasis, structural abnormalities 1
• Consider immunologic evaluation, sweat test for cystic fibrosis 1

Treatment Algorithm for Dry Cough with Fever

Consider Pertussis

Paroxysmal cough (with or without inspiratory "whoop") accompanied by post-tussive vomiting strongly suggests Bordetella pertussis infection. 3

• Test for pertussis with PCR or culture if clinically suspected 3
• Treat with azithromycin (10 mg/kg/day for 5 days, maximum 500 mg/day) if pertussis confirmed or highly suspected 3, 4
• Treatment is most effective in the cataral phase (first 1-2 weeks) but should be given regardless to reduce transmission 3
• Pertussis is highly contagious (80% secondary attack rate); evaluate and treat close contacts 3

Evaluate for Asthma/Reactive Airways

If dry cough without pertussis features, consider cough-variant asthma, but do not empirically treat without supporting evidence. 1, 2

• Obtain spirometry if available (reliably performed in children >6 years) 1
• Look for exercise-induced symptoms, nocturnal cough, family history of atopy 1
• If asthma suspected: Trial of bronchodilator plus inhaled corticosteroid for 2-4 weeks maximum 1
• Discontinue if no response within this timeframe to avoid unnecessary medication 1

Critical Environmental and Supportive Measures

Eliminate tobacco smoke exposure and other environmental pollutants immediately, as these worsen cough regardless of underlying etiology. 1, 2

Address parental expectations and concerns directly, as chronic cough significantly impacts quality of life for both child and family. 1, 2

Common Pitfalls to Avoid

Do not empirically treat for asthma, GERD, or upper airway cough syndrome without specific clinical features supporting these diagnoses. 2 This leads to:

• Unnecessary medication exposure 2
• Delayed diagnosis of treatable bacterial infection 1
• Increased healthcare costs 5

Do not ignore fever in the context of chronic cough—fever suggests active infection (bacterial or atypical) requiring antimicrobial therapy rather than watchful waiting. 1

Do not continue ineffective treatments beyond 2-4 weeks—if a trial therapy doesn't work within this timeframe, stop it and reassess rather than continuing indefinitely. 1, 2