What medication is appropriate for an 18-year-old with dry cough and severe sore throat?

Treatment for 18-Year-Old with Dry Cough and Severe Sore Throat

For symptomatic relief, give acetaminophen or an NSAID like ibuprofen for the severe sore throat, and consider honey for the dry cough—avoid cough suppressants and do not prescribe antibiotics unless bacterial pharyngitis is confirmed. 1

Immediate Symptomatic Management

For Severe Sore Throat

• Acetaminophen or NSAIDs (such as ibuprofen) are strongly recommended as first-line analgesic/antipyretic agents for moderate to severe pharyngitis symptoms 1
• Multiple randomized, double-blind, placebo-controlled studies demonstrate that NSAIDs like ibuprofen provide superior pain relief and fever reduction compared to placebo in both adults and adolescents with pharyngitis 1
• Acetaminophen also provides significant pain relief, though improvement may not be equivalent to ibuprofen 1
• Avoid aspirin in this age group if there's any possibility of viral illness due to Reye syndrome risk 1

For Dry Cough

• Honey is the recommended first-line treatment for cough relief—give one teaspoon as needed 1
• If honey alone is insufficient and cough is truly distressing, codeine linctus (15 mg/5 mL) or codeine phosphate tablets can be used: start with 15-30 mg every 4 hours as needed, up to four doses in 24 hours, with maximum of 240 mg daily 1
• Dextromethorphan at 60 mg provides maximum cough reflex suppression and can be prolonged, though generally recommended doses are subtherapeutic 1
• Avoid cough suppressants in chronic bronchitis or bronchiectasis as they cause sputum retention 1

Determining Need for Antibiotics

When to Test for Strep Throat

You must determine if this is bacterial (Group A Streptococcal) pharyngitis requiring antibiotics:

• Perform rapid antigen detection test (RADT) or throat culture if clinical features suggest bacterial pharyngitis 1
• Clinical features favoring bacterial pharyngitis: tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough 1
• Do NOT treat empirically with antibiotics without confirmation 1

If Strep Positive

• First-line: Penicillin or amoxicillin for 10 days 1
• For penicillin allergy (non-anaphylactic): narrow-spectrum cephalosporins (cephalexin or cefadroxil) for 10 days 1
• For penicillin allergy (anaphylactic-type): azithromycin 500 mg daily for 5 days OR clarithromycin for 10 days 1
• Clindamycin is reasonable with ~1% resistance in the US 1

If Strep Negative or Viral

• Antibiotics provide NO benefit for viral pharyngitis or acute cough from common colds 1, 2
• Continue symptomatic management only 1

What NOT to Prescribe

• Corticosteroids are not recommended despite minimal symptom reduction (~5 hours), given efficacy of analgesics and potential adverse effects 1
• Tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, and older fluoroquinolones should never be used for pharyngitis 1
• Antihistamines have minimal to no efficacy for cough relief and are associated with adverse events 3, 4

Follow-Up and Red Flags

When to Reassess

• Review if symptoms worsen or fail to improve after 48 hours 2
• Re-evaluate if cough persists beyond 2-4 weeks for emergence of specific etiologic pointers 3

Warning Signs Requiring Urgent Evaluation

• Difficulty breathing or swallowing
• Drooling or inability to handle secretions
• High fever (≥38.5°C) persisting >3 days 3
• Severe unilateral throat pain (possible peritonsillar abscess)
• Muffled voice or trismus

Common Pitfalls to Avoid

• Do not prescribe antibiotics due to patient pressure when testing doesn't confirm bacterial infection 1, 2
• Do not use broad-spectrum antibiotics when narrow-spectrum agents are appropriate—they're more expensive and select for resistant flora 1
• Do not combine multiple OTC cough/cold products as this increases risk of adverse events from duplicate ingredients 4
• Do not assume all sore throats need antibiotics—most are viral and self-limited 1