What is the appropriate management for a cough concerning for pneumonia?

Management of Cough with Concern for Pneumonia

For outpatient adults with acute cough and suspected pneumonia, use clinical features and C-reactive protein (CRP) to guide diagnosis, obtain chest radiography when abnormal vital signs are present, and initiate empiric antibiotics per local guidelines only when pneumonia is confirmed or imaging cannot be obtained—but avoid antibiotics entirely when vital signs and lung exam are normal. 1

Diagnostic Approach

Clinical Features Suggestive of Pneumonia

The following symptoms and signs increase likelihood of pneumonia 1:

• Respiratory symptoms: Cough, dyspnea, pleuritic chest pain 1
• Systemic symptoms: Fever ≥38°C, sweating/rigors, body aches 1, 2
• Vital sign abnormalities: Tachypnea, tachycardia 1, 2
• Physical examination: New focal chest signs (crackles, diminished breath sounds) 1, 2
• Absence of upper respiratory features: Lack of runny nose increases pneumonia likelihood 1, 2

Laboratory Testing

C-Reactive Protein (CRP) should be measured to strengthen diagnostic accuracy 1:

• CRP ≥30 mg/L plus suggestive symptoms strongly supports pneumonia diagnosis and warrants treatment 1, 2
• CRP <10 mg/L makes pneumonia unlikely 1, 2
• CRP 10-50 mg/L without dyspnea and daily fever makes pneumonia less likely 1

Procalcitonin should not be routinely measured in outpatient settings 1, 3

Imaging

Chest radiography should be ordered when abnormal vital signs are present or clinical suspicion is high to confirm infiltrates and improve diagnostic accuracy 1, 2. Radiographic confirmation of new infiltrates within 48 hours establishes definitive pneumonia diagnosis 2.

Microbiological Testing

Routine microbiological testing is not needed for outpatient pneumonia 1. Consider testing only if results would change therapy 1.

Treatment Decisions

When to Initiate Antibiotics

Use empiric antibiotics in the following scenarios 1:

• Pneumonia is clinically suspected (based on symptoms, signs, and CRP ≥30 mg/L) and imaging cannot be obtained 1, 2
• Radiographic evidence of pneumonia (infiltrates) is present 1, 2
• Patient has abnormal vital signs with clinical features suggesting pneumonia 1

Follow local and national antibiotic guidelines for empiric therapy selection 1, 2.

When to Avoid Antibiotics

Do not prescribe antibiotics when 1, 3:

• Vital signs are normal and lung examination is normal 1, 3
• No clinical or radiographic evidence of pneumonia exists 1
• Features suggest viral upper respiratory infection 3

This approach can reduce unnecessary antibiotic prescriptions by approximately 9% 4.

Consider Influenza

For patients with suspected influenza presenting within 48 hours of symptom onset 1:

• Initiate antiviral treatment per CDC guidelines 1
• This may decrease antibiotic usage, hospitalization, and improve outcomes 1
• Consider antivirals for high-risk patients even if testing is delayed 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for microbiological results when pneumonia is clinically or radiographically confirmed 2
• Do not treat with antibiotics based solely on cough without supporting clinical features, abnormal vital signs, or radiographic evidence 1, 5
• Do not use procalcitonin for routine outpatient diagnosis—it adds no benefit over CRP and clinical assessment 1, 3
• Do not prescribe antibiotics when clinical features suggest viral infection or when the patient appears well with normal vital signs 1, 3, 5

Severity Assessment and Follow-Up

• Reassess patients who show no improvement or worsening at 48-72 hours after initiating treatment 3
• Consider alternative diagnoses if patient fails to respond to appropriate therapy 3
• Escalate care for patients with persistent high fever beyond 3-4 days, new dyspnea, or chest pain 3