What symptomatic cough therapy should be added to the antibiotic regimen for an otherwise healthy adult outpatient with community‑acquired pneumonia?

Symptomatic Cough Therapy for Outpatient Community-Acquired Pneumonia

For an otherwise healthy adult outpatient with community-acquired pneumonia, there is insufficient evidence to recommend any specific nonantibiotic symptomatic cough therapy; focus should remain on appropriate antibiotic treatment and supportive care. 1

Evidence Base for Symptomatic Cough Treatments

The 2019 CHEST guideline explicitly states that there is insufficient evidence to make recommendations for or against specific nonantibiotic, symptomatic therapies for acute cough due to pneumonia. 1 This represents a critical gap in the evidence base—while cough is a cardinal symptom of CAP, randomized controlled trials evaluating symptomatic cough treatments in this population are lacking. 1

Available Symptomatic Agent

• Benzonatate is FDA-approved for symptomatic relief of cough and may be considered if cough is particularly bothersome, though its efficacy specifically in CAP has not been established in rigorous trials. 2
• The typical dose is 100–200 mg orally three times daily as needed for cough. 2

Priority: Appropriate Antibiotic Therapy

The most effective "cough therapy" for CAP is appropriate antimicrobial treatment of the underlying infection. 1, 3 Symptomatic cough improvement follows successful treatment of the pneumonia itself. 3

First-Line Antibiotic Regimens for Outpatients

For previously healthy adults without comorbidities:

• Amoxicillin 1 g orally three times daily for 5–7 days is the preferred first-line agent, providing superior pneumococcal coverage (90–95% of S. pneumoniae isolates including many penicillin-resistant strains). 4, 5, 6
• Doxycycline 100 mg orally twice daily for 5–7 days is an acceptable alternative covering both typical and atypical pathogens. 4, 5, 6
• Macrolides (azithromycin or clarithromycin) should only be used when local pneumococcal macrolide resistance is documented <25%; in most U.S. regions resistance is 20–30%, making macrolide monotherapy unsafe as first-line. 4, 5, 6

For outpatients with comorbidities (COPD, diabetes, chronic heart/liver/renal disease, recent antibiotic use):

• Combination therapy: amoxicillin-clavulanate 875/125 mg twice daily PLUS azithromycin (500 mg day 1, then 250 mg daily) for 5–7 days. 4, 5, 6
• Alternative: respiratory fluoroquinolone monotherapy (levofloxacin 750 mg daily OR moxifloxacin 400 mg daily) for 5–7 days, reserved for β-lactam allergy or contraindications due to FDA safety warnings. 4, 5, 6

Supportive Care Measures

While specific cough suppressants lack evidence in CAP, general supportive measures are appropriate:

• Adequate hydration to help thin secretions. 5
• Rest to support immune function and recovery. 5
• Antipyretics (acetaminophen or ibuprofen) for fever and discomfort, which may indirectly reduce cough triggered by fever or pleuritic pain. 5

Treatment Duration and Monitoring

• Minimum treatment duration is 5 days, continuing until the patient is afebrile for 48–72 hours with no more than one sign of clinical instability. 4, 3, 5
• Typical total course for uncomplicated CAP is 5–7 days. 4, 3, 5
• Clinical review at 48 hours (or sooner if symptoms worsen) is essential to assess response, oral intake, and adherence. 4, 5

When to Escalate Care

Indicators of treatment failure requiring hospital referral include:

• No clinical improvement by day 2–3 of therapy. 4, 5
• Development of respiratory distress (respiratory rate >30/min, oxygen saturation <92%). 4, 5
• Inability to tolerate oral antibiotics due to vomiting or gastrointestinal dysfunction. 4, 5
• New complications such as pleural effusion or sepsis. 4, 5

Critical Pitfalls to Avoid

• Do not delay or substitute antibiotic therapy with cough suppressants alone—the underlying infection must be treated. 1, 3
• Avoid codeine-containing cough suppressants in outpatient CAP due to lack of evidence, potential for respiratory depression, and risk of dependence. 1
• Do not use fluoroquinolones as first-line agents in uncomplicated outpatient CAP due to FDA warnings about serious adverse events (tendon rupture, peripheral neuropathy, aortic dissection) and rising resistance. 4, 5
• Never use macrolide monotherapy in regions where pneumococcal macrolide resistance exceeds 25% (most of the United States), as this leads to treatment failure. 4, 5, 6