A patient with a 14‑day history of productive cough now has worsening symptoms after a cold—what is the next step in management?

Management of 14-Day Productive Cough with Worsening Symptoms

Perform a chest radiograph to rule out pneumonia, as a productive cough lasting 14 days with worsening symptoms meets clinical criteria for suspected community-acquired pneumonia. 1

Immediate Assessment: Rule Out Pneumonia

The European Respiratory Society guidelines establish that pneumonia should be suspected when acute cough is accompanied by any one of the following: new focal chest signs, dyspnoea, tachypnoea, or fever lasting >4 days. 1 Your patient's 14-day duration with worsening symptoms warrants radiographic confirmation, as clinical features alone cannot reliably distinguish pneumonia from acute bronchitis. 1

Key Clinical Features to Assess

• Fever >4 days, new focal chest signs (crackles, diminished breath sounds, dull percussion), dyspnoea, or tachypnoea strongly suggest pneumonia and mandate chest X-ray 1
• Focal auscultatory abnormalities increase pneumonia probability from 5–10% to 39%, making physical examination findings critical 1
• Absence of upper respiratory tract infection symptoms (rhinorrhea, sore throat) combined with fever and dyspnoea further elevates pneumonia likelihood 1

If Chest X-Ray is Normal: Post-Infectious Cough Management

If radiography excludes pneumonia, this represents post-infectious cough—a self-limited condition lasting 3–8 weeks after viral infection that does NOT require antibiotics. 2, 1

First-Line Treatment Algorithm

1. Inhaled ipratropium bromide 2–3 puffs (17–34 mcg per puff) four times daily has the strongest evidence for attenuating post-infectious cough, with response expected within 1–2 weeks 2, 1

2. Add first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) plus intranasal corticosteroid spray (fluticasone or mometasone) to address upper airway inflammation 2, 3

3. Supportive care with guaifenesin 200–400 mg every 4 hours (up to 6 times daily) to help loosen secretions 2

Second-Line Options (If Quality of Life Remains Impaired)

• Inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) may be added if cough persists despite ipratropium and significantly affects daily function, allowing up to 8 weeks for full response 2, 1

• Oral prednisone 30–40 mg daily for 5–10 days should be reserved ONLY for severe paroxysms that markedly impair quality of life, and only after ruling out upper airway cough syndrome, asthma, and GERD 2, 1

If Chest X-Ray Shows Pneumonia: Antibiotic Therapy

Tetracycline or amoxicillin are first-choice antibiotics for community-acquired pneumonia. 1 In case of hypersensitivity, newer macrolides (azithromycin, roxithromycin, or clarithromycin) are alternatives in regions with low pneumococcal macrolide resistance. 1 National/local resistance patterns should guide final antibiotic selection. 1

Critical Pitfalls to Avoid

Do NOT Prescribe Antibiotics for Post-Infectious Cough

Antibiotics are explicitly contraindicated for post-infectious cough unless there is documented bacterial sinusitis or early pertussis infection. 2, 1 The European Respiratory Society emphasizes that therapy with antibiotics has no role, as the cause is ongoing airway inflammation—not bacterial infection. 1, 2

Do NOT Ignore Red Flags Requiring Re-Evaluation

• Hemoptysis, fever development, weight loss, or night sweats mandate immediate reassessment and chest radiography 2
• Cough persisting beyond 8 weeks must be reclassified as chronic cough and systematically evaluated for upper airway cough syndrome, asthma, and GERD 2, 1

Do NOT Overlook Pertussis

Consider pertussis if paroxysmal cough with post-tussive vomiting or inspiratory "whoop" develops, requiring immediate macrolide therapy and isolation for 5 days. 1, 4

Expected Timeline for Response

• Ipratropium bromide: 1–2 weeks 2
• Upper airway treatment (antihistamine-decongestant): days to 1–2 weeks 2
• Inhaled corticosteroids: up to 8 weeks for full effect 2
• Post-infectious cough natural resolution: typically 3–8 weeks from initial infection 2, 1

When to Reassess

Arrange clinical review at approximately 6 weeks if symptoms persist, with repeat chest radiograph for smokers and those over 50 years. 2 If all empiric therapies fail after 8 weeks, consider high-resolution CT chest and bronchoscopy to evaluate for bronchiectasis, interstitial lung disease, or occult endobronchial lesions. 2, 1