What's the next step for an elderly female patient with a history of hyperlipidemia, atrial fibrillation (a fib), and coronary artery bypass graft, who has a persistent cough despite completing courses of azithromycin and prednisone, and is still taking Cefpodoxime (cefpodoxime), with a negative chest x-ray?

Next Step: Stop Antibiotics and Treat as Postinfectious Cough

This patient has postinfectious cough following a viral upper respiratory infection, and the next step is to discontinue the cefpodoxime immediately, as antibiotics have no role in postinfectious cough and are explicitly contraindicated. 1 The negative chest x-ray, absence of fever, and lack of purulent sputum exclude bacterial pneumonia, making continued antibiotic therapy inappropriate and potentially harmful. 1

Why Antibiotics Must Be Stopped

• The American College of Chest Physicians explicitly contraindicates antibiotics for postinfectious cough, as the cause is not bacterial infection and therapy provides no benefit while contributing to antimicrobial resistance. 1
• Key features excluding bacterial infection include: non-purulent sputum, no fever, clear lungs on examination, and negative chest x-ray in an otherwise stable patient. 1
• The patient has already completed 6 days of dual antibiotic therapy (azithromycin and cefpodoxime) without improvement, further confirming this is not a bacterial process. 1

Recommended Treatment Algorithm for Postinfectious Cough

First-Line: Inhaled Ipratropium Bromide

• Prescribe inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily, which has the strongest evidence for attenuating postinfectious cough. 1
• Expected response time is 1-2 weeks. 1
• This anticholinergic agent reduces cough by blocking vagal efferent pathways that mediate the cough reflex. 1

Second-Line: Consider Upper Airway Cough Syndrome (UACS)

• If ipratropium provides inadequate relief after 1-2 weeks, add treatment for UACS with a first-generation antihistamine-decongestant combination (such as brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine). 1
• Add an intranasal corticosteroid spray (fluticasone or mometasone). 1
• UACS is one of the three most common causes of chronic cough and should be addressed systematically. 2

Third-Line: Inhaled Corticosteroids

• If quality of life remains significantly affected after ipratropium treatment, consider inhaled corticosteroids such as fluticasone 220 mcg or budesonide 360 mcg twice daily. 1
• Allow up to 8 weeks for full response, as these agents suppress airway inflammation and transient bronchial hyperresponsiveness. 1

Reserve Oral Prednisone Only for Severe Cases

• Prednisone (30-40 mg daily for 5-10 days) should only be prescribed if severe paroxysms significantly impair quality of life AND other common causes have been ruled out or adequately treated. 1
• The patient already completed a prednisone burst without resolution, suggesting this is not the appropriate therapy at this stage. 1

Special Considerations for This Patient

Evaluate for ACE Inhibitor Use

• Although not mentioned in the history, if this patient is receiving an ACE inhibitor for her cardiovascular history, it must be stopped immediately, as ACE inhibitors cause chronic cough in a significant percentage of patients. 2
• Cough resolution typically occurs within a few days to 2 weeks of stopping the drug, but median time is 26 days. 2

Consider GERD as Contributing Factor

• Given her atrial fibrillation and likely anticoagulation, evaluate empirically for GERD with high-dose PPI therapy (omeprazole 40 mg twice daily) if cough persists beyond 8 weeks despite treatment for UACS and postinfectious cough. 2, 1
• GERD-related cough often lacks typical GI symptoms ("silent GERD") and may require 2 weeks to several months for response. 1
• Implement dietary modifications: limit fat intake, eliminate coffee, tea, chocolate, citrus, and alcohol; avoid eating 2-3 hours before bedtime; elevate head of bed. 3

Asthma Evaluation if Needed

• If cough persists beyond 8 weeks total duration, perform bronchoprovocation challenge or empiric trial of inhaled corticosteroids and beta-agonists to evaluate for cough-variant asthma. 2, 1
• Response to asthma therapy may take up to 8 weeks. 1

Critical Pitfalls to Avoid

• Do not continue antibiotics beyond the current course – this provides no benefit and increases antimicrobial resistance. 1
• Do not jump to oral prednisone – it should be reserved for severe cases after other therapies have failed. 1, 4
• Do not assume the cough will resolve on its own – systematic treatment of postinfectious cough and its common comorbidities (UACS, asthma, GERD) is necessary. 2, 1
• Recognize that chronic cough is frequently multifactorial – the cough will not resolve until all contributing causes have been effectively treated, so continue successful therapies while adding the next intervention rather than stopping and switching. 1

Red Flags Requiring Re-evaluation

• Instruct the patient to return immediately if fever develops, hemoptysis occurs, or symptoms worsen. 1
• If cough persists beyond 8 weeks total duration, reclassify as chronic cough and systematically evaluate for UACS, asthma, and GERD using the algorithmic approach. 2, 1
• Consider high-resolution CT chest and bronchoscopy if all empiric therapies fail and concerning findings develop (crackles, clubbing, weight loss, night sweats). 1