What to do for a 51-year-old female with chronic cough and congestion for 2 months unresponsive to multiple antibiotics?

Management of Chronic Cough Unresponsive to Antibiotics in a 51-Year-Old Female

Stop all antibiotics immediately—they provide no benefit for chronic cough and contribute to antibiotic resistance while increasing risks of C. difficile infection and other complications. 1, 2

Why Antibiotics Have Failed

• Antibiotics are ineffective for chronic cough because the underlying causes are typically non-infectious: upper airway cough syndrome (UACS), asthma, non-asthmatic eosinophilic bronchitis, or gastroesophageal reflux disease (GERD)—not bacterial infection. 3, 1
• The most common mistake with apparent antibiotic failure is adding more antibiotics rather than reconsidering the diagnosis. 4
• Continued antibiotic use after 2 months significantly increases risk of C. difficile infection, antibiotic-resistant organisms, and adverse drug effects without clinical benefit. 2, 5

Immediate Diagnostic Steps

Obtain a chest X-ray if not already done to exclude structural abnormalities, malignancy, interstitial lung disease, or other serious pathology. 1

Systematically evaluate for the three most common causes of chronic cough in adults:

1. Upper Airway Cough Syndrome (UACS) - Most Common

• Start first-generation antihistamine/decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) as first-line therapy. 3, 6
• Begin with once-daily bedtime dosing for several days before advancing to twice daily to minimize sedation. 6
• Add intranasal corticosteroid (e.g., fluticasone, mometasone) to decrease nasal inflammation. 6
• Monitor for side effects including urinary retention, increased intraocular pressure, sedation, insomnia, and worsening hypertension. 6
• Response typically occurs within days to 2 weeks, though complete resolution may take several weeks to months. 3

2. Asthma or Cough-Variant Asthma

• Consider empiric trial of inhaled corticosteroids if cough persists despite UACS treatment and adversely affects quality of life. 6, 1
• Note that cough alone without wheezing is often over-diagnosed as asthma; response to inhaled corticosteroids helps confirm the diagnosis. 3

3. Gastroesophageal Reflux Disease (GERD)

• Evaluate for GERD symptoms (heartburn, regurgitation, nocturnal cough). 3
• Do not prescribe empiric proton pump inhibitors without clinical features of GERD—this approach lacks evidence for unexplained chronic cough. 1

Alternative First-Line Therapy for Postinfectious Component

If there's a clear history of initial respiratory infection 2 months ago:

• Inhaled ipratropium bromide is the evidence-based first-line treatment for postinfectious cough (Grade B recommendation). 1
• This works by reducing mucus hypersecretion and bronchial hyperresponsiveness. 1

Sequential Treatment Algorithm

Week 1-2: First-generation antihistamine/decongestant + intranasal corticosteroid 3, 6

Week 2-4: If partial response, continue UACS therapy and add inhaled ipratropium bromide 6, 1

Week 4-6: If inadequate response, add inhaled corticosteroid trial for possible asthma component 6, 1

Beyond 8 weeks: If cough persists despite systematic empiric treatment, refer to pulmonology for specialized evaluation including possible bronchoscopy, high-resolution CT, or methacholine challenge testing. 3, 1

Critical Medications to Review

Check if patient is taking an ACE inhibitor (lisinopril, enalapril, etc.)—this causes chronic dry cough in 10-20% of patients. If present, stop immediately and replace with an angiotensin receptor blocker. 1

Symptomatic Relief Options

While addressing underlying causes:

• Dextromethorphan 60 mg (not standard OTC doses of 15-30 mg which are subtherapeutic) provides maximum cough reflex suppression. 6, 7
• Benzonatate 100-200 mg three times daily works peripherally and may provide short-term relief. 7
• Simple remedies like honey can be effective for symptomatic relief. 7

Common Pitfalls to Avoid

• Never continue or add more antibiotics without clear evidence of bacterial infection (purulent sputum, fever, infiltrate on imaging). 1, 2
• Don't use cough suppressants if the cough is productive and helping clear secretions. 1
• Avoid nasal decongestant sprays beyond 3-5 days due to rebound congestion risk. 6
• Don't assume all chronic cough is asthma—this leads to inappropriate inhaled corticosteroid overuse. 3

Red Flags Requiring Immediate Pulmonology Referral

• Hemoptysis 7
• Abnormal chest X-ray (masses, infiltrates, lymphadenopathy, interstitial changes) 1
• Constitutional symptoms (fever, weight loss, night sweats) 3
• Progressive dyspnea 7