Definition and Management of Recurrent Cough and Pneumonia
Definitions
Recurrent pneumonia is defined as two or more separate episodes of lower respiratory tract infection accompanied by fever, leukocytosis, and purulent sputum production, separated by an asymptomatic interval of at least 1 month or radiographic clearing between episodes. 1 Clinical improvement and radiological clearing should result after appropriate antimicrobial therapy. 1
Chronic cough is defined as cough lasting longer than 8 weeks in adults. 2 Cough lasting longer than 3 weeks but less than 8 weeks is considered persistent or subacute cough and exceeds the case definition for acute bronchitis. 3
Clinical Approach to Suspected Pneumonia
Initial Assessment
For patients presenting with acute cough and suspected pneumonia, assess vital signs and perform chest examination to determine the likelihood of pneumonia. 3 The absence of vital sign abnormalities (heart rate <100 beats/min, respiratory rate <24 breaths/min, oral temperature <38°C) and absence of focal consolidation on chest examination (rales, egophony, or fremitus) sufficiently reduces the likelihood of pneumonia to the point where further diagnostic testing is usually not necessary. 3
Diagnostic Testing
Pneumonia should be suspected when one or more of the following are present: new focal chest signs, dyspnea, tachypnea, pulse rate >100 beats/min, or fever >4 days. 3
C-reactive protein (CRP) testing can help stratify risk: CRP <20 mg/L at presentation (with symptoms >24 hours) makes pneumonia highly unlikely; CRP >100 mg/L makes pneumonia likely. 3 Acute cough with CRP <10 mg/L or between 10-50 mg/L in the absence of dyspnea and daily fever is less likely to be caused by pneumonia. 3
For patients with acute cough and abnormal vital signs secondary to suspected pneumonia, order chest radiography to improve diagnostic accuracy. 3 In cases of persisting doubt after CRP testing, chest X-ray should be considered to confirm or reject the diagnosis. 3
Routine microbiological testing is not recommended in the outpatient setting unless results may change therapy. 3
Common Pitfall
Purulent sputum does not signify bacterial infection requiring antibiotics. 3 Purulence primarily occurs when inflammatory cells or sloughed mucosal epithelial cells are present and can result from either viral or bacterial infection. 3 The vast majority of cases (≥90%) of uncomplicated acute bronchitis have a nonbacterial cause. 3
Antibiotic Management
When to Prescribe Antibiotics
Do not routinely use antibiotics when vital signs and lung exams are normal, even with isolated auscultatory findings. 3, 4 The absence of vital sign abnormalities has a 97% negative predictive value for pneumonia. 4
Use empiric antibiotics when pneumonia is suspected in settings where imaging cannot be obtained. 3
Initiate antibiotics immediately once radiographic pneumonia is confirmed. 4
Antibiotic Selection and Duration
For community-acquired pneumonia, prescribe antibiotics for a minimum of 5 days. 3 Extension of therapy after 5 days should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. 3
Empirical therapy should cover common pathogens including Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and Staphylococcus aureus. 3 Typical regimens include:
- Amoxicillin, doxycycline, or a macrolide for healthy adults 3
- A β-lactam with a macrolide or a respiratory fluoroquinolone in patients with comorbidities 3
For COPD exacerbations with clinical signs of bacterial infection (increased sputum purulence plus increased dyspnea and/or increased sputum volume), treat with antibiotics for 5-7 days. 3 Appropriate choices include aminopenicillin with clavulanic acid, a macrolide, or a tetracycline. 3
Evaluation of Recurrent Pneumonia
When to Investigate for Underlying Causes
Consider investigation for bronchiectasis in patients with persistent production of mucopurulent or purulent sputum, particularly with relevant associated risk factors. 3
Investigate for bronchiectasis in patients with:
- Rheumatoid arthritis and symptoms of chronic productive cough or recurrent chest infections 3
- COPD with frequent exacerbations (two or more annually) and previous positive sputum culture for P. aeruginosa while stable 3
- Inflammatory bowel disease and chronic productive cough 3
- Otherwise healthy individuals with cough persisting longer than 8 weeks, especially with sputum production 3
Underlying Conditions to Consider
In young adults with recurrent bacterial pneumonia, consider:
- Cystic fibrosis 5
- Immotile-cilia syndrome 5
- Young's syndrome 5
- Pulmonary sequestration 5
- Bronchiectasis 5
In older adults with recurrent bacterial pneumonia, consider:
- Chronic obstructive lung disease 5
- Bronchial obstruction 5
- Specific malignancies 5
- Hypogammaglobulinemia 5
- Alcoholism 5
- Neurologic diseases 5
- Esophageal abnormalities 5
Red Flag Symptoms Requiring Advanced Imaging
If the patient has fever, weight loss, hemoptysis, or recurrent pneumonia, or has persistent symptoms despite optimal drug treatment, advanced imaging with chest computed tomography scan is indicated. 2
Risk Stratification for Complications
In patients over 65 years of age, the following characteristics are associated with a complicated course and warrant careful monitoring or referral:
- Presence of COPD, diabetes, or heart failure 3
- Previous hospitalization in the past year 3
- Taking oral glucocorticoids 3
- Antibiotic use in the previous month 3
- General malaise 3
- Absence of upper respiratory symptoms 3
- Confusion/diminished consciousness 3
- Pulse >100 beats/min 3
- Temperature >38°C 3
- Respiratory rate >30 breaths/min 3
- Blood pressure <90/60 mmHg 3
In patients under 65 years, diabetes, a diagnosis of pneumonia, and possibly asthma are risk factors for complications. 3 For all age groups, serious conditions such as active malignant disease, liver and renal disease, and other disorders affecting immunocompetence increase risk of complications. 3