How should I treat a 4‑day history of fever, chills, and cough?

Treatment of Fever with Chills and Cough (4 Days Duration)

For an adult with 4 days of fever, chills, and cough, provide symptomatic treatment with paracetamol (acetaminophen) for fever and pain relief, ensure adequate hydration (up to 2 liters daily), and do NOT prescribe antibiotics unless pneumonia is confirmed by chest radiography or clinical criteria are met. 1, 2

Immediate Assessment Required

Determine if pneumonia is present by evaluating for these specific clinical features:

• Fever ≥38°C (100.4°F) combined with any of: new focal chest signs on auscultation (crackles, diminished breath sounds), dyspnea/tachypnea, pleural chest pain, or tachycardia 1
• Abnormal vital signs (tachypnea, tachycardia, fever >38°C) warrant chest radiography to confirm pneumonia 1
• C-reactive protein (CRP) ≥30 mg/L in addition to suggestive symptoms significantly increases pneumonia likelihood 1

If these features are absent and vital signs are normal, this is most likely a viral upper respiratory infection requiring only supportive care 1, 2.

Symptomatic Management (First-Line Treatment)

Fever Control

• Paracetamol (acetaminophen) is the preferred antipyretic for fever and associated discomfort 1, 2
• Use antipyretics to treat fever plus other symptoms causing discomfort, not solely to normalize temperature 1, 2
• Continue analgesics only while symptoms of fever and pain persist 1, 2
• Avoid NSAIDs as first-line until more evidence is available, though paracetamol/ibuprofen combination may be considered if paracetamol alone is insufficient 1, 3

Hydration

• Drink fluids regularly to prevent dehydration, but no more than 2 liters per day 1, 2

Cough Management

• Avoid lying flat on back, as this makes coughing ineffective 1, 2
• Honey (for patients >1 year old) as simple first-line measure 1, 2
• Short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution may be considered if cough is severely distressing 1

When Antibiotics Are Indicated

Do NOT prescribe antibiotics unless one of these conditions is met:

• Confirmed pneumonia on chest X-ray with abnormal vital signs 1
• Clinical pneumonia criteria met: fever ≥38°C for >4 days, new focal chest signs, dyspnea, and tachypnea 1
• Suspected bacterial pneumonia in settings where imaging cannot be obtained, use empiric antibiotics per local guidelines 1

Antibiotics provide NO benefit for viral respiratory infections and cause harm through adverse effects and antimicrobial resistance 1, 2.

Critical Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if any develop:

• Respiratory distress or difficulty breathing 1, 2
• Severe breathlessness causing anxiety or requiring sitting upright/leaning forward 1
• High fever >39°C persisting beyond initial assessment 2
• Altered consciousness or severe drowsiness 4
• Inability to maintain hydration 2

Expected Clinical Course

• Viral respiratory symptoms typically last up to 2 weeks with gradual improvement on supportive care alone 2, 5
• Reassess at 48-72 hours if symptoms worsen or fail to improve 4
• Consider chest X-ray if fever persists beyond 10-14 days or if new respiratory symptoms develop 5

Key Pitfall to Avoid

Do not prescribe amoxicillin or ampicillin if infectious mononucleosis is suspected (posterior cervical lymphadenopathy, prolonged fever, fatigue), as these cause characteristic maculopapular rash in 80-90% of EBV-infected patients 2.