Management of Dry Cough Following Fever in a 15-Year-Old Female
For a 15-year-old with dry cough following fever, provide supportive care with watchful waiting and reassess if the cough persists beyond 3-4 weeks, at which point systematic evaluation for specific causes becomes necessary. 1, 2
Initial Classification and Assessment
- Define the cough duration: Acute cough is defined as lasting <3 weeks in patients ≥15 years of age 1
- This presentation is consistent with post-viral cough, which typically follows an upper respiratory infection and represents persistent upper airway irritation, mucus hypersecretion, or transient bronchial hyperresponsiveness 2
- Most viral coughs resolve within 7-10 days, with 90% resolving by day 21 2
Screen for Red Flags
Before proceeding with conservative management, evaluate for the following concerning features that may indicate serious underlying disease 1:
- Hemoptysis (blood in sputum)
- Prominent dyspnea, especially at rest or at night
- Systemic symptoms: persistent high fever (>38.5°C), weight loss
- Hoarseness or voice changes
- Recurrent pneumonia
- Abnormal respiratory examination findings
If any red flags are present, proceed immediately to chest radiograph and further investigation 1
Evaluate for Pertussis
Given the age and presentation, consider Bordetella pertussis infection if the following features are present 2, 3:
- Paroxysmal coughing fits (severe episodes of repetitive coughing)
- Post-tussive vomiting (vomiting immediately after coughing episodes)
- Inspiratory "whoop" sound after coughing paroxysms
- Known exposure to pertussis or incompletely vaccinated contacts
If pertussis is clinically suspected, initiate macrolide antibiotics (azithromycin or erythromycin) immediately, even before laboratory confirmation, as pertussis has an 80% secondary attack rate in susceptible contacts 2, 4
Primary Management Strategy
For Uncomplicated Post-Viral Dry Cough (No Red Flags):
Supportive care is the cornerstone of management 2, 3:
- Adequate hydration to help thin secretions 3
- Saline nasal drops for nasal congestion relief 3
- Elevate head of bed during sleep to improve breathing 3
- Minimize environmental irritants, particularly tobacco smoke exposure 2, 3
What NOT to Do:
- Do not prescribe over-the-counter cough and cold medications in children under 6 years, and use with extreme caution in adolescents due to lack of proven efficacy and potential adverse effects 2, 3
- Do not prescribe antibiotics for initial management of dry cough following fever without evidence of bacterial infection 3
Follow-Up and Reassessment Timeline
Schedule reassessment at 4 weeks if cough persists 1, 2:
- At 4 weeks, the cough transitions from acute to subacute/chronic cough and requires systematic evaluation 1, 2
- At this point, consider chest radiograph and evaluation for specific causes including:
When to Consider Antibiotics
Antibiotics are indicated ONLY if 3:
- Symptoms persist beyond 10 days without improvement (suggesting bacterial sinusitis)
- Symptoms worsen after initial improvement (biphasic illness pattern)
- Severe onset with high fever (≥39°C) and purulent nasal discharge for ≥3 consecutive days
- Pertussis is clinically suspected (paroxysmal cough with post-tussive vomiting or whoop) 2
If antibiotics are warranted, amoxicillin 45 mg/kg/day divided every 12 hours is first-line for suspected bacterial complications 3
For suspected pertussis, azithromycin is the preferred macrolide antibiotic 2, 4
Common Pitfalls to Avoid
- Premature antibiotic prescription: Most post-viral dry coughs are self-limited and do not require antibiotics 3, 5
- Failure to assess cough quality of life: Use validated tools to assess impact on sleep and daily activities 1
- Missing pertussis diagnosis: Maintain high index of suspicion in adolescents with paroxysmal cough, as immunity from childhood vaccination may have waned 2
- Inadequate follow-up: Failing to reassess at 4 weeks may delay diagnosis of chronic cough conditions requiring specific treatment 1, 2