What treatment is recommended for a patient with nasal congestion, headache, runny nose, and a cough productive of non-purulent sputum, without signs of bacterial infection or inflammatory condition?

Recommend Nonprescription Guaifenesin

This patient has a postinfectious cough following an upper respiratory infection, and antibiotics have no role in treatment as the cause is not bacterial infection. 1 The absence of fever, purulent sputum, and clear lung examination rules out bacterial pneumonia or acute bacterial sinusitis requiring antibiotics.

Clinical Reasoning

This is Postinfectious Cough, Not Bacterial Infection

• The patient's timeline (initial URI symptoms for 3 days, followed by cough for 7 days = 10 days total) and clinical presentation are classic for postinfectious cough, which occurs when cough persists for at least 3 weeks but not more than 8 weeks following an acute respiratory infection 1

• Key features excluding bacterial infection: 1

  • Non-purulent (not yellow/green) sputum
  • No fever (temperature 37°C is normal)
  • Clear lungs except transient wheezes that clear with coughing
  • No crackles suggesting pneumonia
  • Otherwise healthy nonsmoker

• Antibiotics (amoxicillin or azithromycin) are explicitly contraindicated because therapy with antibiotics has no role in postinfectious cough, as the cause is not bacterial infection 1

Why Not Prednisone?

• Prednisone (30-40 mg daily) is reserved for severe paroxysms of postinfectious cough when other common causes (upper airway cough syndrome, asthma, GERD) have been ruled out 1

• This patient has mild symptoms without severe paroxysms, chest pain, or shortness of breath—prednisone would be premature and expose him to unnecessary corticosteroid side effects 1

• The guideline-recommended treatment algorithm for postinfectious cough starts with inhaled ipratropium, then considers inhaled corticosteroids if quality of life is affected, and only uses oral prednisone for severe cases 1

Why Guaifenesin is the Best Answer

• Guaifenesin is FDA-approved to "help loosen phlegm (mucus) and thin bronchial secretions to make coughs more productive" 2, which directly addresses this patient's productive cough with non-purulent sputum

• For acute cough following viral URTI, the most appropriate initial management is supportive care with over-the-counter preparations 1

• While evidence for guaifenesin's efficacy is limited in controlled trials 3, it remains a safe, nonprescription option that aligns with the patient's mild symptoms and the self-limited nature of postinfectious cough 1

• Acute viral cough is almost invariably benign and prescribed treatment can be regarded as unnecessary, but patients report benefit from various over-the-counter preparations 1

Treatment Algorithm for Postinfectious Cough

1. First-line (this patient): Supportive care with nonprescription expectorants like guaifenesin 1, 2

2. If cough persists or worsens: Consider inhaled ipratropium bromide, which may attenuate the cough 1

3. If quality of life is affected despite ipratropium: Consider inhaled corticosteroids 1

4. For severe paroxysms only: Consider prednisone 30-40 mg daily for a short, finite period after ruling out other causes 1

5. If all else fails: Central-acting antitussives such as codeine or dextromethorphan 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for postinfectious cough unless there is clear evidence of bacterial sinusitis or early pertussis infection 1

• Do not jump to prednisone for mild postinfectious cough—reserve it for severe cases that have failed other therapies 1

• If cough persists beyond 8 weeks, consider diagnoses other than postinfectious cough, including upper airway cough syndrome, asthma, or GERD 1

• Recognize that postinfectious cough is self-limited and will usually resolve in time without specific pharmacologic intervention 1

Answer: b. nonprescription guaifenesin