Management of Pediatric Patient with Productive Cough and Leukocytosis
Start amoxicillin-clavulanate immediately at 45 mg/kg/day divided every 12 hours for 2 weeks, as this child has protracted bacterial bronchitis (PBB) with evidence of bacterial infection indicated by the productive cough and leukocytosis with neutrophilia. 1, 2
Initial Clinical Assessment
Determine cough duration and characteristics:
- If cough duration is >4 weeks, this is chronic wet/productive cough requiring antibiotic therapy 1, 3
- If cough duration is <4 weeks but accompanied by leukocytosis (WBC 19.97) and neutrophilia (74%), this represents acute bacterial respiratory infection requiring antibiotics 2
Evaluate for specific "cough pointers" that would change management:
- Coughing with feeding (suggests aspiration) 1, 3
- Digital clubbing (suggests bronchiectasis or chronic suppurative lung disease) 1, 3
- Respiratory distress signs (increased respiratory rate, retractions, cyanosis) 2, 3
- Hemoptysis 4
The laboratory values (WBC 19.97 with neutrophil predominance 0.74) strongly support bacterial infection and mandate antibiotic treatment regardless of cough duration. 2
Antibiotic Treatment Protocol
First-line therapy:
- Prescribe amoxicillin-clavulanate 45 mg/kg/day divided every 12 hours for 2 weeks 1, 2, 5
- This dosing targets the three most common respiratory bacteria: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
- Administer at the start of meals to enhance clavulanate absorption and minimize gastrointestinal intolerance 5
- The every 12-hour regimen is preferred over every 8-hour dosing as it significantly reduces diarrhea incidence (14% vs 34%) 5
If cough resolves within 2 weeks:
If cough persists after initial 2-week course:
- Extend antibiotics for an additional 2 weeks (total 4 weeks) 1, 3
- Continue same antibiotic and dosing 1
If cough persists after 4 weeks of appropriate antibiotics:
- Proceed to flexible bronchoscopy with quantitative cultures and sensitivities 1, 3
- Consider chest CT imaging 1, 3
- Refer to pediatric pulmonology 4
- Evaluate for bronchiectasis, chronic suppurative lung disease, or other underlying conditions 1, 6
Critical Monitoring Parameters
Reassess clinical status at 48-72 hours:
- Monitor for improvement in cough character and frequency 2
- Assess for resolution of fever 2
- Evaluate respiratory status 2
Return immediately if:
- Development or persistence of high fever ≥39°C (102.2°F) 2, 3
- Worsening respiratory distress (increased work of breathing, retractions, grunting) 2, 3
- No improvement after 48-72 hours of antibiotics 2
- Development of paroxysmal cough with post-tussive vomiting or inspiratory "whoop" (suggests pertussis) 2, 3
Important Clinical Pitfalls to Avoid
Do not dismiss this as "just a viral infection":
- The combination of productive cough with WBC 19.97 and neutrophilia 74% indicates bacterial infection requiring antibiotics 2
- Persistent wet/productive cough in children is never normal and always pathological 1, 7
Do not use over-the-counter cough medications:
Do not delay antibiotic therapy:
- Early intervention may prevent progression to bronchiectasis 3, 6
- PBB and bronchiectasis likely represent opposite ends of the same disease spectrum 6
Do not substitute different formulations incorrectly:
- Two 250 mg/125 mg tablets are NOT equivalent to one 500 mg/125 mg tablet due to different clavulanate content 5
- Use suspension formulations for accurate weight-based dosing in pediatric patients 5
Supportive Care Measures
Environmental modifications:
- Eliminate tobacco smoke exposure 4
- Ensure adequate hydration to thin secretions 2
- Elevate head of bed during sleep 2
The leukocytosis with neutrophil predominance (19,970 cells with 74% neutrophils = absolute neutrophil count ~14,778) confirms this is bacterial infection, not viral, making antibiotic therapy essential and non-negotiable. 2