What is the recommended prescription for a patient with acute cough in an urgent care setting, considering potential underlying causes and comorbidities such as asthma or chronic obstructive pulmonary disease (COPD)?

Acute Cough Management in Urgent Care

For acute cough in the urgent care setting, do not routinely prescribe antibiotics, antitussives, or other medications—most cases are viral and self-limiting. 1 If symptomatic relief is needed, recommend honey and lemon as first-line treatment, or prescribe dextromethorphan 30-60 mg for short-term use only. 2, 3

Initial Assessment

Your primary goal is to rule out serious illness, particularly pneumonia, not to prescribe medication for uncomplicated viral bronchitis. 1

Red Flags Requiring Different Management:

• Vital sign abnormalities (tachycardia, tachypnea, fever) or asymmetrical lung sounds suggest pneumonia—chest X-ray is indicated 1
• Increasing breathlessness may indicate asthma or anaphylaxis 2
• Purulent sputum with fever and malaise suggests serious lung infection 2
• Significant hemoptysis or suspected foreign body requires specialist referral 2

Key History Points:

• ACE inhibitor use—if present, stop the medication and switch drug classes 1
• Smoking status—counsel on cessation 1
• Underlying COPD, asthma, or bronchiectasis—consider acute exacerbation rather than simple acute bronchitis 1

What NOT to Prescribe

The 2020 CHEST guidelines explicitly recommend against routine prescription of:

• Antibiotics 1
• Antiviral therapy 1
• Antitussives 1
• Inhaled beta-agonists 1
• Inhaled anticholinergics 1
• Inhaled corticosteroids 1
• Oral corticosteroids 1
• NSAIDs 1

This represents the strongest contemporary evidence against the common urgent care practice of prescribing these medications. 1 Despite this, research shows 94% of urgent care patients receive antibiotics and 78% receive cough suppressants—practices not supported by evidence. 4

If You Must Prescribe Something

First-Line: Non-Pharmacological

Recommend honey and lemon—this is as effective as pharmacological treatments for benign viral cough and costs nothing. 2, 3, 5 This recommendation comes from multiple guideline societies including the British Thoracic Society. 2

Second-Line: Dextromethorphan (if patient demands medication)

• Dose: 30-60 mg for maximum cough suppression (not the standard 10-15 mg found in most OTC preparations) 2, 5
• Maximum daily dose: 120 mg 5
• Duration: Short-term only (days, not weeks) 3, 5
• Caution: Check combination products to avoid excessive acetaminophen 5

Important caveat: Standard OTC dosing of dextromethorphan is subtherapeutic—maximum cough reflex suppression occurs at 60 mg. 2, 5 However, the evidence for dextromethorphan efficacy is mixed, with some studies showing no benefit over placebo. 5

Alternative for Nocturnal Cough

First-generation antihistamines (e.g., diphenhydramine) can suppress cough through sedative effects, making them useful specifically for nighttime cough disrupting sleep. 2, 5 However, they cause drowsiness. 5

What About Codeine?

Do not prescribe codeine or codeine-containing products—they have no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, physical dependence). 2, 5

Special Circumstances Requiring Treatment

If Pertussis is Suspected:

• Perform diagnostic testing 1
• Prescribe macrolide antibiotics 5
• Recommend isolation for 5 days from treatment start 5

If Underlying Asthma/COPD Exacerbation:

This is not uncomplicated acute bronchitis—adjust chronic disease medications appropriately. 2 Consider that 65% of patients with recurrent "acute bronchitis" actually have mild asthma. 1

If Bacterial Infection Develops:

If the cough worsens (not just persists) and bacterial superinfection is suspected, then consider antibiotics. 1 But this is the exception, not the rule.

Follow-Up Strategy

Advise patients to return for reassessment if:

• Cough persists beyond 3 weeks 1
• Cough worsens despite initial management 1
• New concerning symptoms develop 1

At that point, consider targeted investigations: chest X-ray, sputum culture, peak flow measurements, or inflammatory markers. 1

Common Pitfalls to Avoid

• Prescribing antibiotics reflexively—this is the most common error and contributes to antimicrobial resistance 1
• Using subtherapeutic doses of dextromethorphan (10-15 mg) when 30-60 mg is needed for effect 2, 5
• Failing to consider asthma as the underlying cause in patients with recurrent episodes 1
• Not counseling about expected duration—most viral coughs resolve within 2-3 weeks 1

Patient Satisfaction

Patient satisfaction depends more on physician-patient communication than on antibiotic prescription. 1 Explain that acute cough is viral, self-limiting, and that antibiotics won't help and may cause harm. Set realistic expectations about symptom duration (1-3 weeks). 2