What is the best course of treatment for a previously healthy adult patient presenting with a 5-day history of cough and congestion?

Management of Acute Cough and Congestion in a Previously Healthy Adult

For a previously healthy adult with 5 days of cough and congestion, antibiotics should NOT be prescribed, as this presentation represents an uncomplicated viral upper respiratory infection or acute bronchitis that will resolve on its own within 1-2 weeks. 1, 2

Initial Assessment: Rule Out Conditions Requiring Specific Treatment

Before confirming this is simple acute bronchitis, you must exclude pneumonia and pertussis:

Pneumonia exclusion criteria - No chest radiograph is needed if ALL of the following are absent: 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)

Pertussis must be actively ruled out, especially given the 5-day duration. Ask specifically about: 2, 3

• Paroxysmal coughing fits
• Post-tussive vomiting (vomiting after coughing)
• Inspiratory "whooping" sound

If any pertussis features are present, obtain a nasopharyngeal swab immediately and start azithromycin or clarithromycin without waiting for results, then isolate the patient for 5 days. 1, 3

Antibiotic Use: Explicitly Contraindicated

Antibiotics have no role in uncomplicated acute bronchitis and should not be prescribed. 1, 2 This recommendation is based on high-quality evidence showing:

• No clinical benefit for symptom duration or severity 1
• Contribution to antimicrobial resistance 2
• Risk of adverse effects including allergic reactions and C. difficile infection 2

The presence of purulent (green or yellow) sputum does NOT indicate bacterial infection and should NOT prompt antibiotic prescription. 3

Recommended Symptomatic Treatment

For congestion and rhinorrhea, prescribe a first-generation antihistamine/decongestant combination (e.g., chlorpheniramine + pseudoephedrine or phenylephrine). 1, 4, 3 This is the most effective treatment for upper respiratory symptoms. Start once daily at bedtime for a few days to minimize sedation, then advance to twice daily if tolerated. 1

For productive cough with mucus, recommend: 2

• Honey and lemon as first-line (cost-effective, no adverse effects)
• Guaifenesin (FDA-approved to fluidify mucus and bronchial secretions)

For dry, bothersome cough disrupting sleep, consider dextromethorphan or codeine for short-term symptomatic relief. 1, 4 However, cough suppression is not logical when significant sputum production is present. 4

If wheezing is present, prescribe an inhaled beta-2 agonist bronchodilator (e.g., albuterol). 1, 2 Transient wheezing that resolves with coughing may not require treatment, but persistent wheezing requires bronchodilator therapy.

Medications to AVOID

Do NOT prescribe: 2, 4

• Antibiotics (amoxicillin, azithromycin, etc.)
• Expectorants other than guaifenesin
• Mucolytics
• Antihistamines alone (newer non-sedating antihistamines are ineffective for acute cough)
• Nasal decongestant sprays for >3-5 days (risk of rebound congestion)

Expected Timeline and When to Re-evaluate

Set appropriate expectations: 1, 2

• Cough will be worst during the first few days
• Symptoms should gradually and progressively improve over the next 1-2 weeks
• Complete resolution typically occurs within 3 weeks

Instruct the patient to return if: 1, 2, 3

• Symptoms worsen after initial improvement (biphasic course suggests bacterial sinusitis or pertussis)
• Fever does not resolve within 48 hours
• Cough persists beyond 2-3 weeks without constant improvement
• New symptoms develop (chest pain, shortness of breath, high fever)

Special Considerations for Persistent Cough

If cough persists ≥3 weeks but <8 weeks, this is defined as post-infectious cough. 2, 3 First-line treatment is inhaled ipratropium bromide (2-3 puffs four times daily). 2, 3 If this fails after 2 weeks, evaluate for asthma, non-asthmatic eosinophilic bronchitis, or gastroesophageal reflux disease. 3

Common Pitfalls to Avoid

• Do not diagnose "acute bronchitis" without first ruling out common cold, asthma, or COPD exacerbation, as this label increases antibiotic prescribing. 1
• Do not assume purulent sputum means bacterial infection - this is a viral infection characteristic. 3
• Do not prescribe prednisone - this is reserved only for severe post-infectious cough paroxysms after failure of other therapies. 2
• Do not ignore wheezing - it requires evaluation and bronchodilator treatment. 2