What is the appropriate evaluation and management for a 7‑day history of productive cough with yellow‑green sputum, generalized weakness, myalgias, and pleuritic chest pain that worsens with deep breathing?

Evaluation and Management of 7-Day Productive Cough with Systemic Symptoms

This patient requires immediate chest radiography and empiric antibiotic therapy for presumed community-acquired pneumonia (CAP), given the 7-day duration of productive purulent sputum, pleuritic chest pain, systemic symptoms (fever, myalgias, weakness), and high likelihood of bacterial infection. 1

Initial Clinical Assessment

Key diagnostic features supporting bacterial pneumonia:

• Yellow-green (purulent) sputum production indicates bacterial infection rather than viral bronchitis 1
• Pleuritic chest pain (pain with deep breathing) suggests pleural involvement, reinforcing bacterial pneumonia 1
• Duration of 7 days with systemic symptoms (weakness, body aches) exceeds typical viral upper respiratory infection 2
• The combination of productive cough, fever, and pleuritic pain creates a clinical syndrome highly specific for CAP 2, 1

Critical distinction: This is NOT acute bronchitis. Acute bronchitis should only be diagnosed when pneumonia has been ruled out clinically or radiographically, and when common cold, asthma, or COPD exacerbation are excluded 2. The presence of pleuritic chest pain and purulent sputum for 7 days makes pneumonia far more likely 1.

Immediate Diagnostic Workup

Mandatory investigations before treatment:

• Chest radiograph (PA and lateral views) to confirm pneumonia, assess extent, and identify complications like parapneumonic effusion 2, 1
• Pulse oximetry to assess oxygenation status; if SpO₂ <92%, obtain arterial blood gas 1
• Two sets of blood cultures before initiating antibiotics 2, 1
• Sputum Gram stain and culture if patient can produce adequate purulent specimen 2, 1
• Complete blood count to assess for leukocytosis supporting bacterial infection 1
• Basic metabolic panel to guide antibiotic dosing and assess for complications 1

Clinical predictors that reduce need for chest X-ray: If ALL of the following are absent, pneumonia is unlikely: (1) heart rate >100 bpm, (2) respiratory rate >24 breaths/min, (3) temperature >38°C, (4) focal consolidation findings on exam 2. However, given this patient's pleuritic pain and purulent sputum, imaging remains essential 1.

Treatment Algorithm

If Pneumonia Confirmed and Patient Stable for Outpatient Management:

• Amoxicillin-clavulanate 875/125 mg PO twice daily PLUS azithromycin 500 mg PO daily for 5-7 days 1
• This provides coverage for Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens (Mycoplasma, Chlamydia, Legionella) 1

If Hospitalization Required (any of the following):

• Respiratory rate ≥24 breaths/min 1
• SpO₂ <92% on room air 1
• Systolic BP <90 mmHg 1
• Multilobar infiltrates on imaging 1
• Inability to tolerate oral intake 1

Hospital regimen: Ceftriaxone 1-2 g IV daily PLUS azithromycin 500 mg IV/PO daily 1. This dual therapy is superior to β-lactam monotherapy and reduces mortality 1.

If Chronic Productive Cough (>4 weeks) Rather Than Acute:

• The American Thoracic Society recommends a 2-week antibiotic trial targeting common respiratory bacteria 3
• If cough persists after 2 weeks, extend antibiotics for an additional 2 weeks 3
• If cough persists after 4 weeks total, investigate for bronchiectasis, aspiration, or immunodeficiency 3

Critical Pitfalls to Avoid

Do NOT use amoxicillin monotherapy for suspected pneumonia—it lacks atypical pathogen coverage and is associated with higher treatment failure rates 1. Always combine a β-lactam with a macrolide or respiratory fluoroquinolone 1.

Do NOT diagnose "acute bronchitis" and withhold antibiotics when purulent sputum and pleuritic chest pain are present for 7 days 2. While routine antibiotics for viral acute bronchitis are not justified 2, this clinical picture suggests bacterial pneumonia requiring treatment 1.

Do NOT delay antibiotics while awaiting culture results if pneumonia is suspected—empiric therapy should begin immediately after cultures are obtained 1.

Consider pertussis (whooping cough) if paroxysmal cough with post-tussive vomiting or inspiratory "whoop" develops; treat immediately with a macrolide and isolate for 5 days 2, 3.

Monitoring and Follow-Up

• Clinical reassessment at 48-72 hours to confirm defervescence and symptom improvement 1
• If no improvement by 72 hours, repeat chest imaging and consider therapy escalation or complications (empyema, resistant organisms) 1
• Repeat chest radiograph at 6 weeks if symptoms persist or patient is a smoker, to exclude underlying malignancy 1
• Pneumococcal vaccination (PCV20 or PCV15→PPSV23) after recovery to prevent recurrence 1

Special Considerations

Red flags requiring immediate investigation (not empiric antibiotics): 3

• Hemoptysis
• Digital clubbing
• Chronic purulent sputum (always pathological, suggests bronchiectasis or aspiration) 3
• Failure to thrive or weight loss
• Coughing with feeding (aspiration risk) 3

Subacute cough (3-8 weeks): If this represents postinfectious cough following viral illness, consider transient bronchial hyperresponsiveness and treat with inhaled corticosteroids or ipratropium rather than antibiotics 2. However, the presence of purulent sputum argues against simple postinfectious cough 2.