What is the recommended treatment for a patient with a persistent cough, chest congestion, and productive sputum, suspected of having a bacterial infection, with a history of hypertension and currently taking amlodipine (calcium channel blocker)?

Supportive Care Only is Recommended

This patient should receive supportive care without antibiotics at this time. 1 She presents with acute cough (12 days duration) following a viral illness in her household, without fever, with normal vital signs, and no clinical features suggesting pneumonia or bacterial infection.

Clinical Assessment Against Antibiotic Criteria

This patient does not meet established criteria for antibiotic therapy in lower respiratory tract infections:

• No pneumonia suspected: She lacks new focal chest signs, dyspnea, tachypnea, or fever lasting >4 days—all required to suspect pneumonia 2, 1
• No fever present: She is afebrile, which argues strongly against bacterial infection 1
• Normal vital signs: Pulse 76/min, respirations 16/min, oxygen saturation 98%—all reassuring 2
• Viral prodrome: School-aged children were sick first, suggesting viral transmission 1

The change in sputum color from brown to green is not an indication for antibiotics. Purulent sputum alone does not indicate bacterial infection in acute bronchitis and commonly occurs with viral infections. 2

Why Antibiotics Are Not Indicated

European Respiratory Society guidelines are clear that antibiotics should only be considered in lower respiratory tract infections when patients have: 2, 1

• Suspected or confirmed pneumonia
• Age >75 years with fever
• Cardiac failure
• Insulin-dependent diabetes mellitus
• Serious neurological disorder

This patient meets none of these criteria. 2 She has controlled hypertension on amlodipine, which is not an indication for antibiotics. 2

For acute bronchitis without pneumonia, antibiotics show no benefit over placebo and increase side effects without improving outcomes. 2

Recommended Management

Symptomatic treatment:

• Dextromethorphan or codeine may be prescribed for the bothersome productive cough keeping her awake 2, 1
• Do not prescribe expectorants, mucolytics, antihistamines, or bronchodilators—these have no proven benefit in acute lower respiratory tract infections 2, 1

Follow-up instructions (critical to provide):

• Return if fever develops and persists >4 days 2, 1
• Return if dyspnea or respiratory distress develops 2, 1
• Return if new focal chest signs appear 2, 1
• Expect symptoms to resolve within 3 weeks; if persistent beyond 3 weeks, reevaluation is needed 1

Why Other Options Are Incorrect

Amoxicillin-clavulanic acid (option a): Not indicated without evidence of bacterial infection, pneumonia, or meeting high-risk criteria. 2, 1 Prescribing antibiotics without proven bacterial infection increases resistance and provides no benefit. 3

Mycoplasma antibodies (option c): Not useful for acute management. Serologic testing does not guide immediate treatment decisions and results would not be available for days. 2

Sputum culture (option d): Not indicated in uncomplicated acute bronchitis without pneumonia. 2 Sputum cultures are difficult to interpret due to contamination with upper airway flora and do not change management in this clinical scenario.

Common Pitfall to Avoid

The scattered wheezing may represent post-viral bronchial hyperreactivity rather than bacterial infection. 1 If wheezing becomes problematic, consider a short-acting bronchodilator trial, but this is distinct from antibiotic therapy. The key is recognizing that purulent sputum + wheezing ≠ bacterial infection requiring antibiotics in the absence of fever, pneumonia, or high-risk features. 2, 1