When should antibiotics be given to someone with a cough and fever?

When to Give Antibiotics for Cough and Fever

Antibiotics should NOT be routinely given to patients with cough and fever unless there is clinical evidence of bacterial pneumonia or the patient has COPD/severe pre-existing illness with signs of bacterial infection (increased sputum purulence plus increased dyspnea and/or sputum volume). 1

Clinical Decision Algorithm

Step 1: Distinguish Upper vs. Lower Respiratory Tract Infection

• Upper respiratory tract infection (URTI): Normal lung auscultation, symptoms above vocal cords → No antibiotics needed 1
• Lower respiratory tract infection (LRTI): Requires further assessment 1

Step 2: For LRTI - Differentiate Bronchitis from Pneumonia

Acute Bronchitis (90% of LRTI cases):

• Cough with retrosternal discomfort, wheeze, sputum production
• Normal or diffuse bronchial rales on auscultation
• No focal chest signs
• Antibiotics NOT indicated in previously healthy adults 1

Pneumonia - Requires Antibiotics:

• Fever >37.8°C 1
• Tachycardia >100 bpm 1
• Polypnea >25/min 1
• Focal signs on auscultation (crepitations, rales) 1
• Chest pain 1
• Overall impression of severity 1

Step 3: Special Populations That DO Need Antibiotics

COPD Patients with Exacerbation:

• Antibiotics recommended when bacterial infection is suspected, defined as increased sputum purulence PLUS at least one of: increased dyspnea OR increased sputum volume 1
• Duration: 5 days is sufficient 1
• Preferred agents: Doxycycline, co-amoxiclav, or macrolide 1

Previously Well Patients - Consider Antibiotics If:

• Significant worsening of symptoms after initial presentation 1
• Recrudescent fever (fever returning after initial improvement) 1
• Increasing breathlessness 1
• Symptoms persisting >7 days with fever 1

Patients with Severe Pre-existing Illnesses:

• Antibiotics strongly recommended even without pneumonia 1

Antibiotic Selection When Indicated

For Community-Acquired Pneumonia:

• First-line: Amoxicillin 3g/day (for adults >40 years or with comorbidities) 1
• Alternative: Macrolide (for adults <40 years without comorbidities in epidemic context) 1
• Duration: Minimum 5 days, extend only if clinical stability not achieved (resolution of vital sign abnormalities, ability to eat, normal mentation) 1

For COPD Exacerbation/Bronchitis with Bacterial Features:

• Preferred: Doxycycline 200mg loading then 100mg daily, OR co-amoxiclav 625mg three times daily 1
• Alternative: Macrolide (clarithromycin 500mg twice daily or erythromycin 500mg four times daily) 1
• Duration: 5 days 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral bronchitis in healthy adults - purulent sputum alone does NOT indicate bacterial superinfection 1
• Do not use antibiotics to "prevent" bacterial superinfection - no evidence supports this practice 1
• Avoid delayed prescriptions without clear instructions - if used, instruct patients to start only if no improvement after 2 days or worsening symptoms 1
• Reassess within 48-72 hours - fever should resolve within this timeframe with effective treatment; if not, reconsider diagnosis rather than extending duration 1
• Do not substitute two 250mg/125mg amoxicillin-clavulanate tablets for one 500mg/125mg tablet - they contain different amounts of clavulanic acid and are not equivalent 2