Treatment for Cough and Congestion Lasting 5 Days
For an otherwise healthy adult with 5 days of cough and congestion, antibiotics should NOT be prescribed—this is viral acute bronchitis, and treatment should focus on first-generation antihistamine/decongestant combinations or simple home remedies like honey and lemon. 1, 2
Confirm This is Viral Acute Bronchitis (Not Pneumonia)
Before treating, verify the patient does NOT have pneumonia by checking for these red flags 1, 2:
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Temperature >38°C (100.4°F)
- Focal chest findings (dullness to percussion, bronchial breath sounds, crackles, egophony, or fremitus)
If all four findings are absent, no chest X-ray is needed and you can confidently diagnose viral acute bronchitis. 1
What TO Prescribe
First-Line: Antihistamine/Decongestant Combination
The most effective treatment is a first-generation antihistamine (like diphenhydramine or chlorpheniramine) combined with a decongestant (like pseudoephedrine). 1, 2 This combination has the strongest evidence for reducing cough in acute viral respiratory infections. 1
Important contraindications to check: glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, or congestive heart failure. 1
Alternative: NSAIDs
Naproxen (Aleve) is strongly recommended as an alternative unless contraindicated by GI bleeding risk, renal failure, or heart failure. 1 Ibuprofen can also be used but carries similar GI and cardiovascular risks. 3
Simple Home Remedies
Honey and lemon are recommended as cost-effective initial therapy with no adverse effects. 1, 2 This is particularly appropriate for patients who prefer non-pharmacologic approaches.
If Wheezing is Present
If the patient has audible wheezing, prescribe a beta-2 agonist bronchodilator (albuterol inhaler, 2 puffs every 4-6 hours as needed). 1, 2 Transient wheezing that clears with coughing may not require treatment. 2
What NOT to Prescribe
Antibiotics: Explicitly Contraindicated
Antibiotics have NO role in acute bronchitis and should NOT be prescribed. 1, 2 They provide zero benefit, contribute to antimicrobial resistance, and cause adverse effects including allergic reactions and C. difficile infection. 2 This applies even when the patient is producing colored phlegm—sputum color does NOT indicate bacterial infection in acute bronchitis. 1
Newer Non-Sedating Antihistamines
Second-generation antihistamines (like loratadine or cetirizine) are ineffective for acute cough and should not be used. 1
Routine Cough Suppressants
Routine use of antitussives is not recommended, though they may occasionally be useful for short-term symptomatic relief if cough is severely disrupting sleep. 1 Dextromethorphan has the most evidence if an antitussive is needed. 1
Mucolytics and Expectorants
Mucokinetic agents are not recommended due to lack of consistent benefit. 1, 2
Expected Timeline and When to Reassess
Cough should be worst in the first few days and gradually improve over 1-2 weeks. 1, 2
Red flags requiring re-evaluation: 1, 2
- Cough worsens after initial improvement (biphasic course—suggests bacterial sinusitis or pertussis)
- No steady improvement after the first week
- Symptoms persist beyond 3 weeks
- Development of high fever, breathlessness, or hemoptysis
If cough persists 3+ weeks, consider alternative diagnoses like pertussis (paroxysmal cough with post-tussive vomiting), bacterial sinusitis, or cough-variant asthma. 2
Common Pitfalls to Avoid
Do not prescribe azithromycin or amoxicillin "just in case"—this is the most common error and directly contradicts evidence-based guidelines. 1, 2
Do not use nasal decongestant sprays (like oxymetazoline) for more than 3-5 days due to rebound congestion risk. 2
Do not ignore wheezing—it requires bronchodilator treatment and may indicate underlying asthma. 2
Do not assume colored sputum means bacterial infection—viral bronchitis commonly produces yellow or green phlegm. 1