What is the next step in managing a patient in their 30s with a history of recent pneumonia, treated with amoxicillin (amoxicillin-clavulanate) and azithromycin, who still has a persistent cough but is otherwise improved with stable vital signs?

Management of Post-Pneumonia Persistent Cough

Reassure the patient and provide symptomatic management only—this persistent cough after treated pneumonia with clinical improvement and stable vital signs requires no additional antibiotics or further workup at this time. 1

Clinical Context and Timeline

This patient presents with subacute cough (likely between 3-8 weeks duration based on "recent pneumonia" plus 7-day treatment course), which is a common and expected finding after community-acquired pneumonia. 1

• Post-infectious cough following pneumonia can persist for 4-8 weeks after appropriate antibiotic treatment and clinical resolution 1
• The patient has already received adequate dual antibiotic coverage (amoxicillin-clavulanate plus azithromycin) covering typical and atypical pathogens 1, 2
• Stable vital signs and clinical improvement indicate successful pneumonia treatment 1

Immediate Management Approach

No Additional Antibiotics Needed

Do not prescribe additional antibiotics. The patient has completed appropriate therapy and shows clinical improvement. 1, 2

• CHEST guidelines explicitly state: "For outpatient adults with acute cough and no clinical or radiographic evidence of pneumonia (when vital signs and lung exams are normal) we do not suggest the routine use of antibiotics" 1
• The combination of amoxicillin-clavulanate plus azithromycin already provided comprehensive coverage for community-acquired pneumonia 1, 2, 3

Clinical Follow-Up Protocol

Schedule a 6-week follow-up visit as recommended by British Thoracic Society guidelines. 1, 2

• This mandatory review should assess for complete symptom resolution 1, 2
• Obtain a chest radiograph at 6 weeks ONLY if: 1, 2
  • Persistent symptoms remain at that time
  • Patient is a smoker
  • Patient is over age 50
  • Any new physical examination findings develop

Symptomatic Management

Provide reassurance and symptomatic treatment for the persistent cough:

• Explain that post-infectious cough is normal and expected, typically resolving within 3-8 weeks after pneumonia treatment 1
• Consider symptomatic cough suppressants if cough is significantly bothersome (though evidence for specific agents is limited) 1

Red Flags Requiring Earlier Re-evaluation

Instruct the patient to return immediately if any of the following develop:

• Fever ≥38°C, tachycardia (heart rate ≥100), or tachypnea (respiratory rate ≥24) 1
• New or worsening dyspnea 1
• Hemoptysis
• Weight loss or night sweats 1
• Worsening or new chest examination findings 1

Common Pitfalls to Avoid

Do not reflexively prescribe additional antibiotics for persistent cough in an otherwise improving patient—this leads to unnecessary antibiotic exposure, resistance development, and potential adverse effects. 1

Do not obtain immediate repeat chest radiography in a clinically stable, improving patient—the British Thoracic Society specifically states "the chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery." 1, 2

Do not misinterpret persistent cough as treatment failure—cough duration alone, in the absence of other concerning features, does not indicate inadequate antibiotic therapy or need for escalation. 1